Police education as a component of national HIV response: Lessons from Kyrgyzstan
Introduction
Situated along the ancient Silk Road linking Europe to Asia, Kyrgyzstan has become an increasingly important transportation corridor for Afghani opium and itinerant labor. This has fueled epidemics of bloodborne and sexually-transmitted infections (STIs) among people who inject drugs (PWID), sex workers, and migrants. Prevalence of HIV reaches 50 times and 5 times the background rate among PWID and sex workers, respectively; three-quarters of Kyrgyz HIV cases can be directly or indirectly attributed to injection drug use (World Health Organization, 2009).
A legal environment that emphasizes public health over punishment and stigmatization of high-risk groups like drug users and sex workers is critical to an effective HIV response (Cohen and Csete, 2006, UNDP, 2012). Relative to its Central Asian neighbors, Kyrgyzstan has been a regional leader in cultivating such an environment, including decriminalization of small-scale drug possession and rejection of criminal penalties for sex work. Even in the context of public health-oriented laws, however, police practices frequently deviate from formal policies because of poor legal and public health knowledge, negative attitudes toward harm reduction, occupational safety concerns, and perverse incentives (Beletsky et al., 2005, Beletsky et al., 2012b, Burris et al., 2004, Rhodes et al., 2006, Beletsky et al., in press, Beyer et al., 2002).
The Kyrgyz HIV response includes innovative structural efforts to harmonize police practice with public health. Starting in 2005, AIDS Foundation East West (AFEW) and its partners conducted a range of police trainings across the country. This has included persuading the Republican Police Academy to integrate a 46-hour “Special Course” on harm reduction delivered by civil society and police professionals to future top brass (AIDS Foundation East-West, 2013). At the police high school, ad-hoc shorter modules were delivered to junior officers-in-training. Among active-duty personnel, over 500 police throughout Kyrgyzstan completed 17 educational programs. These efforts were bolstered by Instruction (“Prikaz”) 417—an internal policy directing police to facilitate HIV prevention initiatives (Beletsky et al., 2012b).
Though varied in setting and audience, these trainings shared core content components: (1) basic public health information on HIV and STIs, (2) law and institutional policy related to sex work and drug use, (3) occupational safety precautions, and (4) contact information for local harm reduction programs. However, none were formally evaluated, which parallels the lack of evaluation of police education by US harm reduction organizations (Beletsky et al., 2011b). At a time when the need to engage law enforcement in effective HIV response has become increasingly recognized (Law Enforcement and HIV Network, 2013), we are not aware of any study evaluating police trainings outside of the US context (Beletsky et al., 2011a, Davis and Beletsky, 2009, Silverman et al., 2012).
In 2010, AFEW mounted a national survey to understand police knowledge, attitudes, and practices related to harm reduction programs across Kyrgyzstan (Beletsky et al., 2012b). This analysis assesses whether having undergone an HIV-prevention training was associated with a set of outcomes conducive to HIV prevention.
Section snippets
Study design
Study methods were detailed elsewhere (Beletsky et al., 2012b). Briefly, a self-administered paper survey of police serving at least one year was distributed in eight diverse, purposefully-selected precincts across Kyrgyzstan. Data were centrally processed by AFEW. The Institutional Review Board at the University of California, San Diego approved the study.
Study instrument
Based on Diffusion of Information Theory (Rogers, 1995) and items from prior studies of police attitudes and training (Beletsky et al., 2011a
Results
As previously reported (Beletsky et al., 2012b), our study achieved an overall response rate of 64% with 319 completed surveys. This analysis focuses on 313 individuals who responded to the training item. Table 1 illustrates that this sample comprised a diverse group of Kyrgyz police, dominated by relatively mature, experienced, and urban male officers.
Based on standard indicators, respondents exhibited high levels of knowledge about HIV transmission and prevention (median of 7 on a 9-item
Discussion
Our analyses support the hypotheses that police training facilitates better integration of policing and public health efforts targeting high-risk groups. Evidence that trainees were significantly less likely to intend to confiscate injection equipment charts a distinct potential of police trainings to mitigate the damage caused by extrajudicial and intensive policing (Aitken et al., 2002, Beletsky et al., 2012a, Cooper et al., 2005, Davis et al., 2005, Human Rights Watch, 2003). In particular,
Conclusion
Increasing recognition of the importance of integration of policing and public health has generated active interest in ways to operationalize collaboration. Educational interventions targeting police have been advanced as a key operational strategy to accomplish this integration (Law Enforcement and HIV Network, 2013). As the number of and support for such educational initiatives across the world is growing, more research is needed to inform benchmarks, design, and evaluation. In particular,
Role of funding source
Funding for the data collection process was provided by the Open Society Foundations’ Sexual Rights and Health and International Harm Reduction Development Programs. Beletsky is also supported by grant number 2R37DA019829 (S.Strathdee, PI) from the National Institutes of Drug Abuse. Views expressed are of the authors and do not necessarily reflect the views of the National Institutes on Drug Abuse, the National Institutes of Health, The Open Society Foundations, or AFEW. These entities had no
Contributors
Shumskaya conceived of the research and Beletsky, Thomas, Smelyanskaya and Shumskaya designed the study. Shumskaya supervised data collection. Artamonova conducted statistical analyses, with input from all other authors. Beletsky wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript.
Conflict of interest
The authors report no conflict of interest connected to any goods or services described.
Acknowledgments
The authors are indebted to research participants, field staff of partner NGOs throughout Kyrgyzstan, and Alexandr Zelitchenko of the Central Asian Center for Drug Policy. Assistance of AFEW staff, especially Ulan Soronkulov and Aijan Dooronbekova proved invaluable. Research assistance provided by Gabrielle Ransford.
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