COVID-19 and prison health

On this page you can find helpful information and verified resources about COVID-19 and prison health.

The page is continuously updated

The International Corrections and Prisons Association (a verified resource)  

Worldwide Prison Health Research & Engagement Network (WEPHREN) (a verified resource)

Preparedness, prevention and control of COVID-19 in prisons and other places of detention. 

Source – WHO

Interim Guidance. COVID-19: Focus on persons deprived of their liberty.

Source – IASC – Inter-Agency Standing Committee

Position Paper COVID-19 preparedness and responses in prisons

SourceUNODC

COVID-19 pandemic: urgent steps are needed to protect the rights of prisoners in Europe. Statement by Commissioner Dunja Mijatović

SourceCouncil of Europe

Statement of principles relating to the treatment of persons deprived of their liberty

SourceCouncil of Europe

Coronavirus: Healthcare and human rights of people in prison

SourcePenal Reform International

Appeal by European NGOs involved in the field of prison health and in the defence of the right to health protection for prisoners

COVID-19 in prison: the Council of Europe must lead on policies to address the Covid-19 challenges

SourceCouncil of Europe

COVID-19: Council of Europe anti-torture Committee issues “Statement of principles relating to the treatment of persons deprived of their liberty”

SourceCouncil of Europe

COVID-19 population management strategy for prisons

Source – www.gov.uk

UNODC, WHO, UNAIDS and OHCHR joint statement on COVID-19 in prisons and other closed settings

Source – UNAIDS

EECA’s response to COVID-19. Prison health.

Evgeniy Yuldashev, peer consultant and social worker, AFEW Kyrgyzstan, about work with (ex) prisoners. 

For reference:

For three years, Evgeniy has been working as a peer consultant with people who are released from prisons and are getting ready for the release with AFEW Kyrgyzstan. His work is to provide support to (ex) prisoners, tell them how to adapt to the social environment and live a full life with HIV and any co-morbidities, such as tuberculosis or hepatitis C.

Changes due to COVID-19

Currently, Bishkek and other big cities of Kyrgyzstan live in the state of emergency. So far, there have been no cases registered in any correctional facilities. The penitentiary system implements a set of measures to avoid any outbreaks of COVID-19 in prisons. First of all, it means that all prisons are closed for visitors, including AFEW Kyrgyzstan staff members. Since 20 March 2020, our peer consultants have not been visiting any institutions.

Fortunately, some of our team members work as social workers in the correctional facilities. Besides, in each institution there are 2-3 volunteers (navigators) from among the prisoners. Thus, we are still able to remain in contact with the prisoners.

Innovations

Currently, one of our key priorities is prevention of the spread of coronavirus.

Prisoners are one of the populations most vulnerable to the new virus. The experience of other countries shows that in prisons the epidemic develops as a fire destroying everything on its way. It can be explained with the living conditions in prisons – overcrowded cells of the detention centers and cramped prison barracks do not allow for social distancing or self-isolation.

In fact, prison life has not really changed – inspections twice a day, waiting lines in the canteens and even long waiting lines in methadone dispensing sites…

From our side, we try to make our contribution to prevent any outbreaks in prisons. The first vital thing to be done is organizing awareness-raising activities. We started with our target group – prisoners who live with HIV. Through our project WhatsApp group and during our telephone calls, we regularly share information about coronavirus with the social workers which they can further share with the prisoners.

There is still a lack of studies on the virus, but the available data shows that HIV-positive people with suppressed viral load and high immunity status do not face a higher risk of infection than the general population. That is why our social workers and volunteers continue their efforts to enroll prisoners into the ART programs and ensure their adherence to treatment in close cooperation with the prison health workers.

As a peer consultant, I always stay in touch with the social workers and through them with the volunteers. We regularly organize phone calls and WhatsApp chats. As they say we are keeping our eyes on the ball. If prisoners have any questions, they can address them with our team through the social workers.

However, it will not be enough to inform people living with HIV to avoid any possible outbreaks. With support of our partners from the UNDP, we prepared a small information brochure, which will help people to learn more about COVID-19, its prevention, symptoms and treatment, and provided the published materials to the Prison Service.

Besides, we received a request for support from the prison administration to facilitate the procurement of personal protective equipment, disinfectants, etc. We submitted this request to our partners from ICAP, who will ensure the procurement of all the necessary supplies.

We are also looking for additional funding to roll out the response to the epidemic. Many prisoners complain about the lack of basic hygiene items. Today it is more important than ever to clean your hands and keep your towel clean. However, unfortunately such people do not always have access to a sufficient stock of such basic things as soap and laundry powder. We are in the process of negotiations with GIZ about the possibility to procure such materials and conduct large-scale awareness-raising activities covering not only prisoners but also prison staff as because of their work duties they are also at high risk of contracting the virus.

So we are keeping ourselves busy and make all the efforts to help our beneficiaries live through this challenging period of time.

 

AFEW International, AFEW Kyrgyzstan and IOM Tajikistan lauched a project for Tajik migrants

Tajikistan is a country marked by a high level of labour migration due to a lack of work in the country. According to official figures, in 2019 more than 500.000 Tajiks left the country for working abroad. The majority works in Russia, where there is a high prevalence of HIV. The proportion of the Tajik migrants among new registered HIV cases in Tajikistan increased  from 10.1 percent in 2014 to 18.8 percent in 2018. Also, little is known about migration of key populations, such as people who use drugs and men who have sex with men (MSM), and their behavior in using health services while working abroad.

To enhance Tajik migrants’ access to HIV services, particularly key populations, IOM Tajikistan together with AFEW International and AFEW Kyrgyzstan launched the project “Improving migrants’ access to HIV services in Tajikistan” in 2019.

What are the goals of this project and how will it change migrants’ lives? Rukhshona Kurbonova, National Professional Officer, Sub-Regional Coordinator on Migration Health for Central Asian countries, talked to AFEW International.

Rukhshona, why it is important to work with migrants?

Migrant workers significantly contribute to the economy of the countries of origin and countries of destination, but are often left out when it comes to health programming. The majority of the Tajik migrants is involved in low skilled jobs, even if they have a good education. The prerequisite for good performance – even for low skilled work – is good health; therefore, both countries of origin and destination benefit from healthy migrants. However, migrants can be stressed by facing a new environment, culture, language, and they are often exposed to poor working and living conditions in the receiving country. This all can put their health at risk. This all circumstances put their health at risk and make migrants vulnerable.

Additionally, since the majority of Tajik migrants are young men from rural areas, where strong social control is part of the traditional patriarchal society, getting into a big metropolis with different norms and morals can impact their sexual behaviour. A difference in social control, little knowledge about prevention of sexually transmitted infections and HIV, alcohol consumption and drug use, and casual sex all play into migrants’ vulnerability to Sexual Transmitted Infections (STIs) and HIV. Therefore, it is important to address their health needs and raise awareness. Integrating migrants into national health programmes and strategies is part of the agenda of the Universal Health Coverage approach promoted by the WHO and other UN organizations including IOM.

The project “Improving migrants’ access to HIV services in Tajikistan” aims to enhance Tajik migrants’ access to HIV services, particularly among key populations. How do you plan to reach this goal and which tools will you use?

The project is composed of two parts: The first part is working in the field with returned migrants in Kulob to raise awareness on safe migration and promoting health seeking behaviour relating STIs and HIV through peer networks. The second part is a regional working meeting with the participation of officials and HIV service NGOs from the Russian Federation, Kazakhstan, Kyrgyzstan and Tajikistan to discuss the essential HIV related package of services for migrants from Central Asia, as recommended by the World Health Organisation.

For the fieldwork in Kulob, IOM will partner with the local NGO “Nakukor”, which has strong experience in working with different groups of migrants. Jointly, they will promote the peer-to-peer approach and hire outreach workers among representatives from the key populations. In addition, within this project supported by AFEW International, IOM will provide free access to HIV tests and survey key populations among migrants to map their sexual behavior and refer them to HIV testing when needed. A legal consultant and venereologists will conduct information sessions for migrants on safe migration and prevention of STIs and HIV. Thanks to the project, two new brochures on safe migration and prevention of STIs and HIV will be developed for migrants. To ensure the sustainability of the project, IOM implements all activities jointly with relevant governments stakeholders – the Tajik Ministry of Labour, Migration and Employment, the Republican Healthy Lifestyle Promotion Center and the Republican AIDS Control Center of the Tajik Ministry of Health and Social Protection.

How long does IOM Tajikistan work with migrants?

IOM Tajikistan has been working on migrants’ health since 2005 and implemented projects on the prevention of STIs, HIV and TB among outbound and inbound migrants. The activities of the Migration Health Unit at IOM Tajikistan are covering the four main pillars needed to ensure the health of migrants holistically: monitoring migrants’ health, advocacy for policy development, provision of migrant sensitive health care services and strengthening inter-country coordination, partnership and networking. IOM Tajikistan has been implementing innovative approaches to reach migrants through peer education, engagement of the diaspora, the creation of multidisciplinary teams in the districts, the publication of communication materials in different languages such as Tajik, Russian, Uzbek, Chinese, Dari, Turkish, and others and by ensuring a multisectoral approach and cross border cooperation. To improve knowledge and skills of the stakeholdres, NGOs and health workers on promoting migrants’ health, a number of educational materials, such as manuals, video clips, and documentaries, were developed and distributed. Additionally, IOM Tajikistan is experienced in providing technical support and promotes the inclusion of migrants’ health issues and concerns into health-related policy documents, such as those developed by the HIV and TB National programmes. Last but not least, we are currently contributing to the development of the National Health Strategy for 2021-2030 and the National Strategy on migration health. IOM Tajikikstan is a member of the Technical Working Group on developing new National AIDS Control Programme and National TB Control Programme for 2021-2025.

Which barriers you might face in Tajikistan and how you are going to overcome them?

Stigma and discrimination are the main barriers faced by migrants and the general population in Tajikistan in accessing HIV services. There is also a high stigma of people who are using drugs, and sexuality is also a taboo topic in society. With our peer-to-peer-approach, we want to reach out to key populations. Through the awareness-raising campaign, working with migration officials and health workers, we want to address and reduce stigma and discrimination of people living with HIV and of key populations. For a better understanding of migrants’ access to HIV services in Tajikistan, the project also has as an operational research component to explore the barriers face by migrants when coming back home.

What do you expect from the project?

The results of the project will improve our understanding of the migrants’ needs concerning HIV services. The project will also help in developing effective communication and health promotion strategies that improve the detection of HIV among the migrant population and refer them for adequate treatment.

Helena Arntz, Junior project officer of AFEW International

Public opinions about migrants, in particular key populations among migrants, are often full of prejudice and stereotyping, which leads to discrimination in the health care system. Migrant workers are in constant movement and often a long time from home, so they can have more difficulties in getting the health care they need. They receive little information about how to be safe abroad, which poses continuous threats to their health and that of their families.

AFEW International has experience with and knowledge on migration in Central Asia and Russia. AFEW International currently also manages two projects in Russian cities Rostov-on-Don and Yekaterinburg to improve healthcare for migrants living with HIV.

In this joint project with IOM Tajikistan we not only want to address the limited information available to key populations among migrants, but also gain better insight in the behavior of this specific group. As the consequences of unsafe migration are not limited to the home country, we will address the needs of migrants at a regional event in Dushanbe. We expect that this will increase cross-border cooperation between Central Asian countries and Russia to improve the needs of key populations among migrants.

 

AFEW International signed “Civil Society Statement on COVID-19 and People who use Drugs”

INPUD, in collaboration with International Drug Policy Consortium and Harm Reduction International, developed a statement ‘In the time of COVID-19: Civil Society Statement on COVID-19 and People who use Drugs’.

Organizations are asking for the international community, including international donors, to act immediately to ensure, through policy guidelines and financial and political support, that national, regional and global responses to the pandemic respect the fundamental rights of all.

The deadline for sign on is Monday, 6 April, by noon (12:00 – London time).

To  sign the statement, please use this link.

The statement

In the time of COVID-19: Civil Society Statement on COVID-19 and People who use Drugs

We, as community and civil society organisations working in drug policy reform and harm reduction, urge the international community to take proactive and coordinated action to protect the health and human rights of people who use drugs in light of the COVID-19 crisis.COVID-19 infection does not discriminate, but magnifies existing social, economic and political inequities. People who use drugs are particularly vulnerable due to criminalisation and stigma and often experience underlying health conditions, higher rates of poverty, unemployment and homelessness, as well as a lack of access to vital resources – putting them at greater risk of infection. The crisis must be an occasion to rethink the function of punishment, to reform the system and to work towards ending the war on drugs. If we are to ‘flatten the curve’, the health of the most marginalised in society must also be protected as an urgent priority.

In times of crisis, uncertainty and upheaval it is imperative that human rights act as an anchor point. Careful and vigilant attention must be paid to non-discriminatory access to health care, human dignity and transparency. Multiple governments emphasise that we are fighting a ‘war’, the use of such terminology justifying a militarised approach that allows for the suspension of rights and freedoms. History shows that extraordinary powers are routinely deployed against the most persecuted in society, who risk being scapegoated in the name of infection control. As states of emergency are declared, the international community must urge caution on the creation of a ‘new normal’ where States derogate from their obligation to serve and protect all persons.

Failure to effectively steer and manage the COVID-19 response will have disastrous consequences. The international community, including international donors, must act immediately to ensure, through policy guidelines and financial and political support, that national, regional and global responses to this pandemic take the needs of people who use drugs into account and respect the fundamental rights of all. We therefore suggest the following recommendations:

1. Protect the right to health: During times such as these, governments have an obligation to ensure that a public health crisis does not become a human rights crisis due to lack of access to adequate health care. In the wake of COVID-19, however, there is great concern that harm reduction services are being closed, not adapting sufficiently rapidly to changing legal and health contexts and that essential resources will be diverted to the COVID-19 response at the expense of equally life-saving work. Inappropriate and restrictive regulations banning or limiting take-home doses and other supplies make complying with lockdowns and social distancing rules extremely difficult. Harm reduction workers report unease about scarcity of resources, lack of coherent policies and programme guidelines on COVID-19, and potential disruptions to global supply chains of essential medicines and equipment, including methadone, buprenorphine, naloxone, needles and syringes, disinfectant, masks and gloves.

The international community must act swiftly to ensure States meet their international obligations to protect the right to life and health. This can be done by issuing strong political statements and clear and comprehensive technical guidance, building on WHO and UNODC  guidelines and national COVID-10 regulations, which unequivocally calls to:

– Declare harm reduction programmes as life-saving services that must stay open. The closure of harm  reduction centres would deprive service users from accessing life-saving interventions and would ultimately lead to over-crowding of centres that remain open, increasing risk of infection.
– Immediately amend restrictive legal and regulatory policies that ban or limit take-home doses due to fear of diversion and that restrict the provision of take-home naloxone to prevent overdoses.
– Enhance service accessibility, develop and implement safety and hygiene protocols and coordinate efforts within the health system to allow for the effective distribution of resources.
– Recognise harm reduction workers as critical healthcare workers so that they can access government stocks of protective clothing.
– Protect and expand the operation of low-threshold services, including outreach, as well as provide housing and shelter for those facing housing insecurity.
– Adequately fund harm reduction services, particularly low-threshold services.

2. Ensure safe supply: Border closures and travel bans around the world will impact the future supply of unregulated substances such as heroin and cocaine. This will have a range of repercussions, including an increase in demand for opiate substitution therapy (OST). Of particular concern is that synthetic drugs such as fentanyl, which are easier to produce and transport, could replace bulkier substances such as heroin, the corollary of this being an exponential increase in overdose deaths.

In light of the above, international and regional bodies must work with member states to:

– Monitor trends of illicit drug markets to provide a rapid response to dangerous and emerging trends, such as increased risk of overdose deaths.
– Ensure increased access to OST to respond to changes in drug supply, through accelerated and flexible entry procedures.
– Deprioritise the enforcement of supply-side control in order to retain some stability in illicit drug markets and prevent market saturation with synthetic drugs.
– Respond to potential disruptions in the production of methadone and buprenorphine and step in when early signs of issues with supply chain management are detected.

3. Protect the right to be free from arbitrary detention: The COVID-19 crisis has spotlighted the public health dangers of overcrowding in prison and detention facilities which are traditional hotbeds for infectious diseases. According to UN data, at least 470,000 persons are incarcerated worldwide for drug use and possession only, while an additional 1.7 million people are incarcerated for other drug offences, many of which are non-violent. In addition, across East and South-east Asia, hundreds of thousands of people who use drugs are detained in compulsory drug detention facilities, with tens of thousands more detained in private drug treatment centres, often against their will, across Asia and Latin America. In such contexts, COVID-19 prevention measures, such as physical distancing, cannot be implemented effectively. Further restrictions on family visits and supervised releases increase isolation and stress during a time of fear, leading to an increase in violence, riots and assault.

The UN High Commissioner for Human Rights has urged governments to reduce the number of people in detention, particularly those without sufficient legal basis. In view of this, the international community must ensure States take action to:

– Decriminalise drug use and possession for personal use as promoted by the UN system and outlined in the UN Common Position on Drugs.
– Reduce the prison population through early release, pardons, amnesties and non-coercive alternatives to incarceration for people detained for drug-related non-violent offences, particularly those on remand, and those most-at-risk individuals, including people living with HIV, TB and COPD, as well as older people.
– Immediately release people who use drugs from compulsory drug detention centres and from private drug treatment centres that apply coercive measures, including involuntary detention.

4. Protect civil and political liberties: Many governments, as part of COVID-19 containment measures, are restricting civil liberties in unprecedented ways, through mass surveillance, including tracking mobile phone data, restricting movement and banning public assembly. Authorities such as police and army personnel are permitted to stop anyone on the street, increasing the chance of hostile interactions with people who use drugs, particularly when they need to purchase drugs or travel for health appointments. The potential misuse of personal data, particularly when it comes to criminalised populations, is of acute concern.

In a joint statement, UN experts have urged States, in accordance with the Siracusa Principles, to exert caution when applying COVID-19 related measures and restrictions that may impinge on human rights, as well as to limit their duration and subject them to regular review. Based on this, we urge the international community to:

– Ensure that emergency declarations and broader extraordinary powers granted under COVID-19 responses are not used to target specific populations or deployed to silence and repress human rights defenders.
– Establish rights-based legal safeguards to govern the appropriate use and handling of personal data to  protect privacy and confidentiality.
– Ensure that exorbitant fines and imprisonment should only be used as a last resort and personal circumstances taken into account, in the event of breaches to protective measures.

5. Protect community and civil society organisations: The COVID-19 pandemic has showed the critical role of communities in the response, as they can react quickly and reach those who are otherwise unreachable, easing the burden on the healthcare system. Furthermore, communities play important watchdog functions when it comes to government transparency and accountability. UN and donor agencies must act to:

– Protect human rights defenders, communities and civil society organisations during this crucial time, by highlighting their critical role in public statements and in their interaction with governments.
– Ensure governments do not impose disproportionate restrictions or obstructions on the work of community  and civil society organisations.
– Establish mechanisms for monitoring human rights compliance, with a particular focus on populations whose rights are commonly violated.

Global problems such as the COVID-19 pandemic require global solutions. We urge the international community to take urgent action to ensure the inherent rights and dignity of people who use drugs are respected and defended in the time of COVID-19. The pandemic has laid bare the failures within our societies. Undoubtedly a serious challenge, COVID-19 must not be exploited by governments to suspend basic rights and freedoms indefinitely, but be a wake-up call to change and repair a broken system that has been overly focused on the punishment of people who use drugs, a policy that is now exacerbating the dangers of COVID-19. The failed war on drugs must end, and health and political systems must be reformed to ensure the health and wellbeing of all.

Voices from the East

AFEW International is actively advocating for the needs to sexual and reproductive health and rights (SRHR) of the EECA region at the international arena.

On 11th March AFEW International on behalf of the partnership ‘Voices from the East’ has submitted a proposal to the Dutch Ministry of Foreign Affairs under the Policy Framework for Strengthening Civil Society for 2021-2025, Grant Instrument SRHR Partnership Fund. Under the leadership of AFEW International, the Voices from the East Partnership brought together 11 strong advocacy and service-oriented organisations and networks to improve access to SRHR for women and youth of Key Population (KP) groups and transgender people:

AFEW International; Eurasian Harm Reduction Association (EHRA); ECOM – Eurasian Coalition On Health, Rights, Gender And Sexual Diversity; Eurasian Union Of Adolescents And Youth Teenergizer; Eurasian Women’s Network On Aids (EWNA); Sex Workers Rights’ Advocacy Network (SWAN); Eurasian Network Of People Who Use Drugs (ENPUD); Dance4life; AFEW-Ukraine; AFEW-Kyrgyzstan; AFEW Kazakhstan.

The partnership plans to work with over 150 local partner organizations from across Easter Europe and Central Asia, advocating for SRHR of women and young people from key populations (living with HIV, sex workers, using drugs, LGBT, in prison) and transgender people as integral part of the Universal Health Coverage (UHC). Through capacity strengthening and mobilizing local communities of key populations the Partnership will work towards evidence-based community-led advocacy for access to high quality, inclusive, stigma-free, integrated and gender transformative SRHR services.

We will know the results of this application in the end of May 2020.

The Dutch Government Policy Framework for Strengthening Civil Society is focused on the West-Africa/Sahel, Horn of Africa, and Middle East and North Africa (MENA) regions. The Voices from the East Partnership is asking for attention to the continued health crisis in the EECA region, being the only region in the world with a growing AIDS epidemic.

Discover your health!

In 2019 the world famous youth program Dance4Life came to Kyrgyzstan. This means that young people in the republic will now be more informed about reproductive health and healthy sexual behaviour.

One of the Dance4Life champions in Kyrgyzstan, Temirlan Irysbekov (20 y.o.), told AFEW International what this project means for him and shared interesting observations from his practice of working with adolescents.

How did you come to the Dance4Life project?

My coordinator in social organization “Red Crescent” told me about this project and offered to apply. I liked the idea because such areas as Sexual and Reproductive Health and Rights (SRHR), surfactants and HIV/AIDS are very important for society. I always wanted to help people by volunteering, conducting trainings in schools and universities, and I liked it.

What do you do for a living?

I am a part-time student at Bishkek State University, freelance programming for companies from the West. Now I work as a barista in Beeline’s office and also do an internship there as a programmer. And for the last four years, I have also been a volunteer at the “Red Crescent” in Kyrgyzstan.

What does it mean for you to be a leader, a champion of Dance4life?

In my understanding, a leader is a person who is listened to by other people, who can deliver any information beautifully and competently. At the same time, to be the Dance4life Champion is a great pride. To be the Dance4life Champion means to share information with people. This project has given me self-confidence, a motivation that drives me to help people. I can confidently support, motivate people around me.

Dance4life aims to work with young people to develop leadership and maintain reproductive health, prevent HIV and sexually transmitted infections. How do you feel about these topics in your environment? Have you and your peers been enlightened on them in school?

My friends are not well informed about the SRH content, as teachers in schools and universities do not talk about it. They don’t even know how to use contraception or how HIV is transmitted. There was a situation when I heard from friends that HIV is transmitted through saliva. I gave them a little training where I told them how HIV is actually transmitted, gave them arguments to dispel all doubts, and shared with them information about contraception.

When I was a schoolboy myself, we had only one class hour dedicated to SRH in all years. When the Red Crescent volunteers started telling us about men and women health, many became shy, turn away, and even cried. Over time, when I shared with people that it is okay to know about your health and we need to know that to protect ourselves, their points of view changed and they became interested and now they can share this knowledge with others.

Why is it important, in your opinion, to be enlightened on these topics?

During my work with various projects, I have repeatedly encountered horrific stories that could have been warned if people knew more about their health and how to keep it. At one of the medical institutions during the training we were told the story of a girl who was playing with her brother’s clothes and decided to try on his pants. At this time she noticed blood – that was a day when her first period started. At that moment, she thought she was pregnant and decided to commit suicide.

What do you remember most about Dance4Life?

At Dance4life we become not just coaches for the guys, but friends that they can trust.

One day, a guy from our team shared his problem with me: he didn’t know how to deal with alcohol addiction. He told his parents he needed money to eat or for smth else, but he actually went to the nearest store and bought himself a beer. It had been going on for a while and he didn’t know how to stop. I redirected him to a youth center with qualified psychologists. At first, I wanted to accompany him, but I realized that he should be willing to do it himself. He made me a promise to come there.

 

So many women, so many fates

 

In Tajikistan, there is an increase in the proportion of sexual transmission of HIV infection from year to year and an increase in the number of women of reproductive age among those registered with the diagnosis established for the first time. That is why in 2019 the public organization “Tajik network of women living with HIV” (TNW+) with the support of AFEW International in the framework of Bridging the Gaps project conducted a study “Key problems of sexual and reproductive health of women living with HIV in Tajikistan through the prism of human rights”.

Before the International Women’s Day on 8 March, Tahmina Khaydarova, head of TNW+ discussed with AFEW International HIV, sex, violence and gender inequality in Tajikistan.

What does sex mean for men and women in Tajikistan?

For men, sex is an opportunity to satisfy their desire, and only then is it a way of making children. For women, sex is almost always a way of making children and extending the family. As a rule, women in Tajikistan cannot talk about sex and take the initiative in sexual relations, as it is considered to be debauchery.

Generally speaking, the sexuality in Tajikistan is highly exposed to traditional gender stereotypes. It is not common here to discuss sexual relations, either in the family or in society. Some people talk about it with their partners, doctors, etc. But even if they do that that they do not really understand the meaning and significance of the concepts of “sex” and “sexual relations” and most often talk about contraception, methods of protection against unwanted pregnancy, hygiene, etc. But not more.

Does it happen because of national traditions and religion?

Yes, in many ways. However, Islam is a religion of peace and good. Islam does not talk about the abuse of women, but there are other factors that affect women’s lives. These are stereotypes, which can be connected with religion.

One of them is “a woman is obliged to take care of her husband and all members of his family, to be obedient and kind”. Therefore, girls have been brought up in a spirit of obedience since childhood. Women themselves think that men’s interests come first. One of the features of families in the republic, especially in villages, is the predominance of extended families, where several generations of adults and children live in the same house – parents, their adult sons/daughters already married, grandparents, adult sisters or brothers. As a consequence, relatives constantly interfere in the husband and wife relationship.

In the family, girls are taught to be housewives, in most cases have no education, especially in villages, and after marriage the girl becomes very dependent on her partner and family members. Without the permission of her elders and husband, a woman has no right to leave her home and receive information about sexually transmitted diseases (STDs) if she wants. A woman must stand one step behind the man in everything: in decision-making, in expressing her opinion. A woman should listen to her husband’s words, she should keep silence, this is respect. It is also rare for women to be able to decide for themselves when, how and with whom to have sex, how many children to have, etc.

At the same time, sexual violence from an intimate partner increases the risk of HIV infection. During our survey, we heard from the respondents reasoning that non-consensual sexual intercourse is a normal phenomenon, and so it should be in the family, “This is your husband: if he wants to do something then you should obey. He’s young, and that’s why you have to satisfy his desires!”

Inequality between men and women in Tajikistan is developed not only in private life, but also in public life, isn’t it?

Yes, gender inequality is one of the problems hindering sustainable development in Tajikistan. Inequality is everywhere – in access to all types of tangible and intangible resources (property, land, finance, credit, education, etc.); in decision-making in all spheres and participation in political life, and violence against women.

Why do women tolerate violence?

Because it fits within the established system of gender inequality in Tajikistan. Men provide for women, control family relations, and therefore can do, in fact, whatever they want.

But the saddest thing is that society does not sufficiently understand the importance of this problem. It is convinced that domestic violence is a private matter. It is considered that the manifestation of abuse of wife, daughter-in-law, sister, etc. or constant control over their life and behavior is not violence but a norm. At the same time, it is widely believed that a woman is to blame if her husband or his relatives use physical force against her. There are many supporters of this opinion among young people, women themselves, and especially among their mothers-in-law. Therefore, in my opinion, special attention should be drawn to solving the problems of relations between mother-in-law and daughter-in-law, the relationship to the wives of migrant workers during the period when their husbands are outside the country, early and forced marriages, etc.

Are women with HIV more vulnerable?  

Definitely! Despite the fact that very often the source of HIV infection for a woman is her husband, she is subjected to violence and discrimination by her husband and his relatives. One woman said that her husband infected her, but did not consider himself guilty. Sometimes he closed the house and left his wife without food, hungry and helpless. One day he even tied her to a pole with a rope and beat her up, and then left for two days. After this she went to her parents, where she was also discriminated.

Why are women with HIV afraid to visit doctors?

Practice shows that those who go to the AIDS centre receive quality care and many are happy with it, including me. However, the main challenges for women are when they go to other health care facilities (for surgery or dentists), including primary health care (PHC). In these facilities women living with HIV (WLHIV) are most likely to experience discrimination against themselves. During focus groups, there were a lot of situations when health care workers refused to provide medical assistance to WLHIV and disclosed their status. Most of these cases were in maternity hospitals, dental clinics and during other surgeries. Therefore, most HIV-positive women are afraid to disclose their status and do not seek services from health care institutions, including primary health care services in their place of residence.

Have you talked to these doctors? What do they say about discrimination against people living with HIV?

We haven’t interviewed the health workers. However, many women believe that the reasons are in the lack of preparedness of health workers to work with PLHIV, as well as the low level of knowledge about HIV among staff. One woman, who went to the clinic, told doctors about her status. They immediately refused her services. The woman said it was a violation of her constitutional rights. But doctors said that she was ill and they could not help her anymore. Just imagine – that’s what the doctors said!

Besides in Tajikistan there is not good medical personnel who have experience working with PLHIV. A lot of professionals are leaving our country.

Let’s imagine – a woman found out about her status, she is ready to be examined, receive treatment and do everything that doctors say. Can she face any obstacles even in this case?

An antiretroviral therapy (ART) in our country is bought from the Global Fund, so there are virtually no interruptions. If a person wants to take ART, he or she can get it at all AIDS centers. But according to WHO’s recommendations, people living with HIV are assigned to PHC services and according to these requirements a person has to get the service at home. Due to the fact that in rural areas and small towns and districts everybody practically knows each other, PLHIV are afraid of disclosing their status. So there is a possibility that they will not apply to these services locally for ART services.

How difficult is it for women to accept their status?

More often it depends on their level of awareness and education – they might not know anything about HIV or have distorted information about the virus. Because HIV does not show strong symptoms in the early stages, women think that they are not sick and that the virus does not affect them. Also, accepting a diagnosis depends on a specialist working with the woman, conducting pre-test and post-test counselling.

Do you plan to use the results of your research in future work?

At the moment, the country is developing a “National Program to combat HIV/AIDS epidemic in the Republic of Tajikistan for the period 2021-2025”, and we have joined the working group on ART treatment and prevention of stigma and discrimination against PLHIV. As part of this platform, we are actively promoting the recommendations in our report.

At the same time, the research results helped us to identify and understand a number of issues, which we have not always paid due attention to before. Therefore, we will use this information in our daily work.

You can find the research here

 

How to help migrants?

According to UNAIDS (www.unaids.org)[1], Russia has the second highest number of labour migrants in the world after the USA. Rostov region is one of the areas where this number is constantly growing. One of the reasons is its geographical position – Rostov region has the biggest borderline with Ukraine. Due to this fact as well as certain developments related to the armed conflict in Donetsk and Lugansk regions, many migrants from Ukraine with different statuses are coming to Rostov region, in addition to the labour migrants from Central Asia.

Are there any special services for migrants in Rostov-on-Don? How is HIV prevention implemented among migrants? Where can migrants seek help without endangering themselves? AFEW International asked these questions to Vyacheslav Tsunik, President of Rostov-on-Don Regional NGO “KOVCHEG – AntiAIDS” and Manager of the Project “HIV Prevention and HIV Services for Migrants in Rostov-on-Don”.

Significant financial support to carry out surveys and provide services to migrants within this project was provided by AFEW International, which, in particular, facilitated coordination with the Central Asian organisations to provide effective support to migrants when they leave their countries of origin and come to Russia.

For reference

Labour migrants are one of the populations most vulnerable to HIV in the world, which is explained by a number of factors. The data of numerous studies show that people coming from the Central Asia have a very low knowledge of infectious diseases: HIV/AIDS, hepatitis B and C. The situation is further aggravated with the low social and economic status of the migrants from Central Asia and the neighbouring countries, lack of access to health services, low level of social support and high prevalence of depression caused by such people living away from their families. High isolation of this social group often leads to HIV transmission inside this community, in particular through contacts with female sex workers, who come from the same countries.

Vyacheslav, how accessible is health care for the labour migrants in Rostov-on-Don?

Health care is provided to the labour migrants who officially live in Russia, in particular in Rostov region, based on their insurance certificates, which they buy when registering their patents. Without certificates, people can access health care on a paid basis, while emergency care if a person’s life is under threat in cases of heart attacks, strokes, catastrophes or accidents is provided to everyone, even with no documents, free of charge and is covered by the state.

How well informed are labour migrants about the problem of HIV?

Surveys among the labour migrants showed that they are not well informed about HIV. In our opinion, the reason is lack of preventive information provided to them in educational institutions in their home countries and when they come to work in Russia.

Do migrants practice any risky behaviours?

In fact, the prevalence of risky behaviours among migrants is approximately the same as among all young people. If we talk about the migrants who come from Asia, e.g. from Tajikistan and Uzbekistan, they have less risky behaviour due to their national customs and traditions. They mostly socialize with their fellow countrymen and they also have respect to older people and certain traditions, which restrict their risky behaviours. As for people from Ukraine and Moldova, they are closer to us, Russians, in terms of their culture and so the situation among them is similar to ours. There are young people who practice high-risk behaviour in terms of HIV. Mainly, they represent key populations. Their share in the total number of migrants is not so big, but they exist and some of them are clients of our organisation. They are not ready to quit their behaviour models.

Are there any differences in the behaviours of HIV-positive and HIV-negative migrants?

There is really a difference in the behaviours of migrants with HIV and those who do not have HIV.

Migrants living with HIV are a closed group. They are not ready to talk about their disease with their family members or their countrymen. Usually, they seek help in HIV organisations only in life-threatening situations or sometimes when they need to stock up their ARVs if there is a danger of treatment interruption.

In Russia, if migrants test positive for HIV, they cannot access free antiretroviral (ARV) therapy as they are foreign citizens. How is this issue resolved?

The situation with supply of ARVs is regulated by relevant provisions. In Russia, government covers ARV therapy only for the citizens. That is why migrants are not able to access free treatment as they are not Russian citizens. However, our organisation has contacts with community organisations in a number of neighbouring countries. We can help people who come to us and assist them is getting support services and ARVs from the countries of their origin.

Currently you are implementing the project “HIV Prevention and HIV Services for Migrants in Rostov-on-Don”. Please tell us more about it.

The goal of our project is to slow down the transmission of HIV through raising the awareness of HIV among migrants and creating services aimed at HIV prevention in migrant populations.

What do we do? Firstly, we train peer consultants from among migrants. Secondly, we provide medical and social support to HIV-positive migrants, giving them access to health services. Thirdly, we have meetings and negotiations with the representatives of diasporas concerning implementation of the prevention tools among migrants in Rostov region and coordinate service provision with the NGOs in the countries of origin of those people who seek our help.

Our organisation, “KOVCHEG – AntiAIDS”, is a community-based organisation of people living with HIV, representatives of vulnerable populations, PLWH, sex workers, LGBT and migrants. For instance, with our current project we trained a peer consultant from the migrant community. This is a woman from Ukraine living with HIV. Another peer consultant that we have, who works with people who use drugs, is also a citizen of Ukraine. Besides, when we carried out a survey among migrants, we had a volunteer supporting us – Ravshan from Uzbekistan – who is a student of a university in Rostov region.

Within the project for migrants, we organized the process to deliver HIV services. In particular, we have rapid testing, pre- and post-test counselling, if necessary provision of ARVs from our reserve stock, medical assays and support in receiving consultations from infectious disease doctors, tests for immune status and viral load, prescription of medications and treatment monitoring. We also inform migrants about the existing legal opportunities to acquire Russian citizenship with HIV status and facilitate people with HIV in obtaining temporary residence permits and Russian citizenship.

How and where do you share information about the services available?

Migrants can access our informational leaflets in the places, which they visit, such as the migration departments, health institutions, which issue the required health certificates to them, pre-deportation detention centres, and higher educational institutions we cooperate with. We use QR codes, allowing migrants to download any information on their smartphones and use it when necessary. As a result, it brings clients to our consultants, who can provide them with any additional information needed.

Name one of your most important recent activities?

Recently, we appealed to the Public Monitoring Commission and asked it to help us access the migrants in pre-deportation detention centres. The Public Monitoring Commission sent an official request to the Ministry of Internal Affairs. We visited the detention centres, met with the migrants living with HIV who stayed there and agreed with the administration of such centres that we would have further access to such migrants living with HIV. We are planning to seek financial opportunities for people living with HIV to receive consultations from infectious disease doctors, get tested for their immune status and viral load and access ARVs for the period of their stay in such institutions. Besides, we are working on developing an appeal to the government officials about the need to provide this category of people with HIV treatment at the expense of the state.

[1]Migrant populations and HIV/AIDS: the development and implementation of programmes: theory, methodology and practice / UNAIDS, UNESCO.

What should be a Primary Care?

In 2019 Anke van Dam, executive director of AFEW International, became a member of advisory board of European Forum for Primary Care (EFPC) to bring knowledge and vast expertise about the EECA region and a great network of contacts with organizations, institutes, agencies and professionals to the EFPC.

Which level does primary care (PC) in the EECA region have nowadays and how to improve that Prof. Jan De Maeseneer, Former Chair of European European Forum for Primary Care, professor emeritus at Ghent University, talked to AFEW International.

Jan, what are the features of a strong primary care (PC)?

We can speak of a strong primary care system when primary care is accessible for a large range of problems, coordinates care on a continuous basis, provides a broad range of health care services in partnership with informal care givers and operates with supportive governance structures, with appropriate financial resources and investments in the development of the primary care workforce. Effective primary care not only prevents diseases at early stages, but also stimulates people to take up healthier life-styles. Overall health is considered within primary care in a more holistic matter, paying attention not only to biomedical and mental health needs, but also to other causes of ill health, such as social determinants (e.g. housing conditions, employment). This makes primary care more person- centred than disease-centred.

PC of which country/region is the most developed nowadays?

Mostly it’s Europe. The countries with relatively strong primary care are Denmark, Estonia, Finland, Lithuania, the Netherlands, Portugal, Slovenia, some regions in Spain and Belgium, and the United Kingdom. Especially I like the examples of Denmark, Estonia, and Finland. These countries have «primary care zones». They look at the population 100-200 000 people and try to install a PC system at that level. That enables give a high degree of participation of all stakeholders. At that scale cooperation is easy, and there is an oversight of population’s health needs, to be addressed. The scale is not too big but big enough to have a “critical mass” for effective intervention for different kinds of problems.

And what about the EECA region?

A good primary care needs democracy. Unfortunately, the former “Semashko” Soviet Union healthcare system (HCS) with policlinics, lacking family physicians, and with doctors that earn very little money don’t allow to set up a good PC. I appreciate the development of Kazakhstan – recently they rediscovered the importance of family physicians. Also, I was very surprised by Kyrgiz Republic. Last year I had the opportunity to lecture for 5th year medical students in Bishkek. In discussion on patients’ stories, they demonstrated a high commitment and patient-centeredness, and excellent skills in clinical decision making. EFPC is trying now to help countries in the EECA region to establish better inter-professional training for primary care, using primary care practices in local communities

It’s important for countries in the region to work together and to build their own PC systems. In Eastern Europe Estonia and Lithuania are doing well. Belarus is not the best example, because of the political situation. It is difficult to combine strong primary care with political dictatorship. In Russia I see some nice things. In Saint Petersburg, for example, there are good departments of family medicine with person-centered approach. But it’s still a difficult country. Good PC is possible only in countries with freedom of speech, human rights, democracy and respect for diversity.

Why good PC is especially important for people living with HIV?

Usually in countries of the EECA region if a person has one of 3 diseases – HIV, TB or Hep, most of the health care resources focus on them. There is no general comprehensive, integrated Primary Care.

PC functions very well when you integrate the care and treatment for those diseases in the broader primary health care system (HCS) as World Health Assembly has clearly stated in resolution 62.12 (in 2009). In Africa I met people who had, for example, 5 diseases, so they had 5 different vertical programs of treatment and 5 different doctors who even didn’t speak with each other. Wise HCS is when you integrate these 5 approaches into one, because, for example, diabetes can be easily an (indirect) consequence of HIV treatment.

Is there a difference between European and the EECA region’s approaches in treatment of HIV+ people?

In western countries HIV/AIDS patients are patients like all the others, they are treated in PC. When primary care providers have problems, they refer patients to the secondary care. Such approach also avoids stigmatizing of people, because when they are treated differently, are included in a separate program, there is a huge risk of stigma. Also, the integrated approach is more cost effective.

How to change people’s minds, also doctors’, towards people with HIV?

Well, first of all, you need to retrain family physicians and other primary care providers. In Russia doctors have limited, if any, training in patient-doctor communication, are not familiar with a human rights approach. For example, in the undergraduate training in my university (Ghent University), there are 55 hours of practicing doctor-patient communications with videotaping, simulated and real patients. Also, it’s necessary to train a sufficient number of family physicians for Primary Care: this requires 3 years of full-time post-graduate training, with specific programs and standards. Besides, it’s important to inform and educate population.

People should understand that every person deserves our respect, and we shouldn’t stigmatize others because they have certain diseases. It’s an open culture in a country, and it is a responsibility of the government and civil society.

What is the goal of EFPC in the region?

EFPC has several goals everywhere, including the EECA region. They are:

– to provide a one-stop information hub and building a substantial collection of information and data over time;

– to guide the development of innovative interventions based on the principles of equity, access, quality, person- and people centeredness, cost-effectiveness, innovation and sustainability.

– to connect four groups of interested parties: patients, citizens and civil society organizations.

– to share communication and information;

– to establish networking and training.

Today we have a good contact with countries from the region, people join our meetings. On the 27 September 2020, we will have a big conference in Ljubljana and in the future possibly also a conference in Central Asia. We want to create a regional platform for exchanging experiences. We hope to bring together health care providers and governments so they can learn from each other how to organize service that reflects people needs.

 

 

 

 

AFEW International and ICAP at Columbia University to improve HIV services in prisons in Kyrgyzstan and Tajikistan

In 2020, AFEW and ICAP at Columbia University will partner to implement «Technical Assistance to Central Asian National HIV Programs to Achieve and Sustain HIV Epidemic Control under the President’s Emergency Plan for AIDS Relief (PEPFAR)» in Kyrgyzstan and Tajikistan, a project funded by PEPFAR through the US Centers for Disease Control and Prevention (CDC). In Kyrgyzstan the project will be implemented by AFEW Kyrgyzstan; in Tajikistan, by NGO SPIN Plus with technical support of AFEW Kazakhstan.

With this project, the partners will strive to reach two important goals:

1) improving the 90-90-90 targets for people who inject drugs (PWID) and people living with HIV (PLHIV) in prisons in Kyrgyzstan and Tajikistan, using new technologies and services;

2) facilitating and improving collaboration between general public health care facilities and health care services within the penitentiary system, ensuring continuity of HIV-related services to people being released from prisons.

AFEW International will be the lead agency working with its in-country AFEW partners and local partners to implement this project in Kyrgyzstan and Tajikistan,” said Daria Alekseeva, Program Director of AFEW International. “We have a proven track record and evidence that working as a regional EECA network has encouraged the exchange of context-specific approaches that help to find appropriate local solutions and models of best practice. We combine local Central Asian knowledge and expertise, exchanging this within the wider EECA region, as well as the added advantage of an international, Netherlands-based Secretariat, contributing to international expertise and innovation. AFEW International – together with AFEW Kyrgyzstan and AFEW Kazakhstan, which will provide technical support to activities in Tajikistan – will aggregate lessons learned from ICAP’s previous work in Kazakhstan and combine those lessons with the methodological approach gained through the past experience of working in prisons in Central Asia to produce practical guidelines and training modules. AFEW International will look for possibilities to pilot this model in Kyrgyzstan and Tajikistan, where political and technical conditions may allow.”

“People living with HIV in prisons are less likely to be on antiretroviral therapy (ART) when compared to general population. They are also less likely to adhere to the prescribed treatment regimen and, therefore, are often viremic,” said Anna Deryabina, ICAP Regional Director for Central Asia. “Lower ART initiation and viral load suppression rates among prisoners are due to many factors, including structural factors, such as lack of trained health care personnel in prisons and limited adherence support and treatment monitoring. Also, lack of coordination between general and prison-based health care services and fragmented service delivery systems lead to many people living with HIV being lost to follow-up and discontinuing treatment after being released from prisons. ICAP has been very effective in improving the quality of HIV services provided to people living with HIV treatment facilities outside of prisons. We really hope that AFEW’s deep knowledge and understanding of subcultures and norms inside the prisons, as well as their experience working with the prison-based health care systems will allow this project to effectively improve the quality of services and HIV outcomes for people living with HIV in prisons.”

“AFEW-Kyrgyzstan is pleased to launch this joint project with ICAP. Under the Project, our organization will be responsible for the implementation of the component to achieve the 90-90-90 goal in the penitentiary system,” said Dina Masalimova, AFEW-Kyrgyzstan Programs Manager. “We plan to work in almost all large prisons in Chui Oblast. Our activities will be aimed at expanding HIV testing coverage with the provision of quality pre- and post-test peer counseling, motivation to start therapy, and adherence development. In addition, we will focus on ensuring that people do not stop their treatment even after release.”

This project is very important to maintaining an effective response to the HIV infection in the country, as 5-10% of all PLHIV in the country are in the prison system. With the high turnover of the prison population, this number can be easily multiplied by half per year.

“We are happy to work in a team with such a highly professional organization as ICAP,” said Masalimova. “It is planned that ICAP specialists will be responsible for medical aspects of providing assistance to PLHIV, and our organization will take over the community element and peer-to-peer support.”

In Kyrgyzstan, AFEW-KG will recruit and train a team of peer navigators representing each layer of the prison sub-population (with a special focus on prison outcasts and pre-release prisoners) in order to identify those who practice risky behaviors and haven’t been tested for HIV in the past six months. AFEW-KG will work with newly identified PLHIV to motivate them to start antiretroviral therapy and take all of the necessary tests. The peer consultants will work as liaisons between patients and prison doctors to ensure that patients are prescribed ART, are adherent to treatment, and that relationships between prison doctors and patients are built on mutual trust.

In addition, AFEW-KG will provide a series of counseling sessions for at least 200 prisoners who are PWID on the benefits of starting methadone-assisted treatment (MAT) and dispelling the myths related to the therapy.

“We believe that this collaboration will yield excellent results and that by the end of 2020 we will be able to see tangible progress on each of the 90-90-90 goals in prisons,” said Masalimova.