Social Protection for People Living with HIV

Hello everyone and welcome! My name is Boyan and I will be the moderator of the discussion for this week. I am originally from Bulgaria and lawyer by training. I have worked at UNDP for twelve years in the field of HIV, human rights, key populations and access to medicines.

The discussion that we are starting is very important because everyone has the right to enjoy social protection. This is not the case with many people living with HIV and key populations. The UNAIDS targets for 2020 for people living with HIV and key populations were very ambitious: 75% of people living with, at risk of and affected by HIV benefit from HIV-sensitive social protection. Needless to say, they were not met and now the situation is even more aggravated because of the COVID-19. Very few countries recognize key populations as beneficiaries of social protection.

This is why social protection is a priority in the new AIDS Strategy (2021-2026) and it must be adequately reflected in the new political Declaration on HIV and in the work of the UN and all member states. We are trying to learn about specific concerns, to hear good practices that could be used in other countries and region, as well as specific recommendations about what each of our entities can do to scale-up HIV sensitive social protection. The very term "social protection" is broad - so it would be good also to discuss what social protection means for people who live with HIV and key population. Please be open, but also respectful to each other, including with the terms and pronouns you use. This discussion follows the Chatham House rule - outside of this forum only "what was said but not who said it" will be conveyed. Please feel free to write in the language you prefer, the message will be automatically translated. Welcome once again - we look forward to a productive discussion!

1. Answering to the first question ("What are the needs and challenges of people with HIV and key populations (in general and for specific populations) and social protection, including in the context of COVID-19, in your country and region?"), there are few issues in my region (EECA):

- Social support programs are largely dependent on donor funding, which is gradually decreasing, and in spite of a lot of discussions around social contracting, countries are slow to take over the responsibility for funding social services for people living with HIV and key populations;

- Legal framework on social protection in many countries does not recognize people living with HIV and key populations as target groups, which makes them either ineligible or significantly reduces their eligibility to receive social services;

- Prevalent stigma, discrimination, criminalization and harmful gender norms, on the one hand, prevent people living with HIV and key populations from seeking health services and social protection, and on the other hand makes those services unaccessible, especially for the most marginalized;

- Another issue is that non-government social workers are not recognized by the law, and some professions (such as outreach workers or peer counselors) do not formally exist; 

- Health and social protection services remain unintegrated, and NGO- and community-led client management programs -- the approach that could effectively bridge the gap -- remain small-scale and not sustainable. In my opinion, client management programs do not receive the attention and support they need, while they are key in making all services truly accessible for those in need;

- Same applies to other social services provided by NGOs and community networks: such services are often available only in large cities, and usually there is a limited number of social services being offered. This is due to a variety of reasons, but mostly because these services were started small-scale as pilots and were never truly scaled up to meet the need.

2. On the second question ("Identify and discuss good practices and lessons learned, as well as opportunities for future action in social protection in national HIV responses and in making social protection schemes HIV and key populations – sensitive. Provide examples from your country and region"), a lot has been done. Some of these achievements are more than just good practices - they are prerequisites for effective social protection for people living with HIV and key populations:

- existence and expansion of networks and groups of people living with HIV and key populations. This being said, countries vary dramatically in terms of the stage of their development. So, if Ukraine has one of the world's largest and strongest networks of people living with HIV, in my own country, Uzbekistan, there is not even a national network of people living with HIV - simply because over the years the Ministry of Justice has repeatedly denied its registration, and no organization led by and representing any of the key populations;

- advocacy around and introduction of NGO social contracting mechanisms - in general and specifically for HIV. There are different approaches to social contracting in the region, and oftentimes the mechanisms are present, but are not funded;

- experience of providing certain services by NGOs and communities in most countries of the region, which needs to be institutionalized, resourced and scaled up. As an example, client management project implemented by AFEW in Central Asia proved to be effective in linking people from key populations with community-friendly social and health services.

3. Finally, on the last question ("What is the main message on social protection for people with HIV and key populations that should be included in the next Political Declaration on HIV and AIDS?"), the emphasis on comprehensive package of services, including social protection, should be as strong as the emphasis on universal access and human rights-based approach (which also includes meaningful engagement as part of the right to participation). These three aspects should be the cornerstones or the pillars of the HIV response.

Финансирование сокращается, тем самым сокращается пространство для гражданского общества, тем самым голос сообществ заглушается. Без достижения изменений существующего карательного законодательства, отмены преследований людей за их сексуальное поведение и практики, возможность самим без морализаторского подхода жить полноценной жизнью, не слушая научно-доказательные рекомендации на основе проведенных исследований по влиянию всех карательных подходов и практик не возможно достичь остановки и снижению бремени ВИЧ, а в условиях Ковид тем более. На сколько бы не обеспечивали страны и правительства разными пакетами услуг, пока людей преследуют прямо или косвенно за поведение и практики, должного влияния от всех услуг не будет достигнуто. Не будет соблюдения прав человека, не будет остановлена сигма и снижена дискриминация, только декриминализация может помогать достигать результаты.

1. What are the needs and challenges of people with HIV and key populations (in general and for specific populations) and social protection, including in the context of COVID-19, in your country and region?

In sub-Saharan Africa, the question is turned on its head, simply because while social protection exists, it does so in limited capacities. ILO for e.g. notes "Africa is the continent where the greatest proportion of the population does not have access to adequate health care and where the incidence of infant mortality is highest. These are only some of the social risks and adversities being faced in day to day life, but Africa is also the continent where the coverage of social security is at its lowest." ILO goes on to say that:

" Many people face major difficulties in accessing health services due to financial constraints. In Kenya and Senegal, 45 per cent of total health expenditure is paid as out-of-pocket payments. Catastrophic health expenditure is one of the major poverty risks for individuals and their families. Paying for medicine and health care may force families into poverty for years." (ibid).

ILO further estimates that "in sub-Saharan Africa only about 10 per cent of the economically active population is covered by statutory social security schemes, most of these being old-age pension schemes, while in some cases also providing access to health-care."

In an overall regional scenario like this, where most people are beyond the pale of any level of state-supported social protection schemes, it is additionally tough for key populations and PLHIV--subject to stigma, discrimination, criminalization, police harassment, lack of updated ID papers, lack of access to formal jobs, etc.--to access social protection schemes.

The role that international nonprofit organisations, regional NGOs and donors can play in such situations is critical--however, that space continues to shrink as donor funding for social schemes, community empowerment, mobilisation dry up and donors prefer to fund interventions that provide them 'bang for bucks'.

So overall, in the sub-Saharan African context--the critical issues are structural: roles of governments, trust in governmental schemes, human rights-based programming, amending laws/policies to read down criminalising statutes that need to be initiated, hand-in-hand with community-designed and led social protection schemes. Some work in this context showed promise during the early part of the COVID-19 pandemic when a few small African organisations shared helplines, provided tangible support to KP/LGBTI/PLHIV to access essential services and resources. Such examples need to be studied and analysed for further upscaling and replication.

Thank you, Piklu Amitrajit Saha for your comments. It looks like in sub-Saharan Africa, as well as in Eastern Europe and Central Asia legal and structural barriers are a major factor that affects access to social protection. Could you please elaborate a bit more:

- Does the general population have access to social protection and what are the main challenges compared to people living with HIV and key populations?

- Are people living with HIV with better access to social protection compared to key populations?

- Which key population(s) is/are left farthest behind?

- Are there any examples of good practices?

Many thanks again!

1. What are the needs and challenges of people with HIV and key populations (in general and for specific populations) and social protection, including in the context of COVID-19, in your country and region?

There is nothing positive (or at least promising) to say about social protection for gay men, other MSM and trans people in the region of Eastern Europe and Central Asia. Wide spread of state-sponsored homophobia doesn't allow for the our communities to access any adequate social protection services.

The main challenge remains legislative framework, that simply doesn't recognise gay men, other MSM and trans people is separate target group. For example in Russia with so-called "gay-propaganda laws" and Uzbekistan and Turkmenistan criminalising homosexual contacts it is impossible to even start conversation with governments on social protection for these groups. The legislative frameworks in EECA needs to be adapted to international standards on SOGI (sexual orientation and gender identity) and HIV.

Moreover, widespread stigma and discrimination towards LGBT among decision-makers in EECA starts a "snowball" that absorbs governmental social workers into the biases based on diversity of sexual orientations and gender identities, different from cisgender and heterosexual majority.

Lack of awareness on SOGI-related issues among the decision-makers doesn't provide the opportunity for policy changes. 

When COVID-19 started, it clearly proved that there is no governmental protection for LGBT at all. Trans people who were involved in sex work, and lost their main source of income because of the pandemic, had to governmental support at all. There are no shelter for LGBT, who have no space due to difficult socio-economic situation.

3. What is the main message on social protection for people with HIV and key populations that should be included in the next Political Declaration on HIV and AIDS?

First of all, is the human rights based approach for the development governmental social protection mechanisms. All the vulnerable groups should be mentioned separately and visibly.

Also, there should be included a mechanism for the community-led organisations to provide social protection services for the communities they serve to. 

The principle "nothing about us without us" should be incorporated for all the decision-making process related to social protection. Gay men and trans people have to be presented, when there is a discussion for the national level programs on social protection mechanisms. 

What are the needs and challenges of people with HIV and key populations (in general and for specific populations) and social protection, including in the context of COVID-19, in your country and region?

Comments: Some of the important needs for the PLHIV and Key populations in terms of welfare measures (Social Protection) are access to HIV prevention and treatment services like lab investigations, ART, Viral load testing, treatment of STI/RTIs, etc. Apart from the HIV services, provision of other Health services is also critical like Mental Health services, screening and treatment of NCDs, etc. Beyond health, the other key areas for the need of welfare measures are access to quality education, access to key Government schemes for food security and housing, Skill development which can improve the access to jobs and livelihoods. In the currently COVID 19 situation, it is seen that majority of the Key populations like Sex workers, Transgenders, etc. had sudden loss of livelihood due to the lockdown measures. This severely impacted their daily life in terms of access to basic needs like food and housing. Also, overall the access to health services by PLHIV and Key populations was a big challenge during the current COVID 19 Pandemic. Also, the social and structural determinants like Stigma and Discrimination continues to be barrier in accessing the welfare measures.

Identify and discuss good practices and lessons learned, as well as opportunities for future action in social protection in national HIV responses and in making social protection schemes HIV and key populations – sensitive.  Provide examples from your country and region.

Comments: Following are some of the key good practices and lessons learned on Social Protection in the Indian context: 

1. The Social Protection measures designed for the PLHIV and Key populations should be based on their needs as different key populations have different specific needs. For example, if someone is an PLHIV from lower socio-economic strata who doesn't belong to any key populations, his/her need will access to free or subsidized HIV Prevention and treatment services, free transportation to access HIV services, access to Government schemes on free dry ration, free housing, etc. Whereas the need of someone who is from the Key population but not HIV positive will be different. In India, the National Government and several State Governments have developed PLHIV specific schemes which has improved the retention of clients in HIV services. However, it is now also felt the specific schemes needs to be developed for key populations, for example, Government of India is now implementing a specific scheme for the Transgender community in India which has sub-components on Health, Education, Housing, Skill development, etc. Basically it is to be realized that Social protection for Key population is beyond HIV services but successful welfare schemes will also contribute to a successful HIV program.

2. The Social Protection measures should be backed by proper legislations to ensure their effective implementation across the country and by following a Human rights approach. In India, the HIV/AIDS Act 2017 and the Transgender Persons (Protection of Rights) Act 2019 are significant legal landmarks which clearly spells out the welfare measures for the PLHIV and Transgender communities. This has ensures active participation of all stakeholders in their implementation.

3. Development of innovative models for implementation of the Social Protection measures at the Grassroot level is helpful. In India, we have developed the District AIDS Prevention and Control Unit (DAPCU) led Single window model where the DAPCU staff in coordination with all other program staff at ART Center, Care and Support center, Targeted interventions, STI Clinic, etc. does the registration and linkages of the PLHIV and key populations to the welfare schemes. During the COVID 19 Pandemic, UNDP India have implemented a project to link these target populations to the COVID 19 Welfare measures. In this activity, apart from few project outreach workers, we utilized this exsisting DAPCU led structure and more than 50,000 PLHIV and key populations were linked to the welfare measures. 

4. Use of Technology for creating awareness and monitoring of the welfare measures. The use of technology can be very useful to create awareness about the different welfare schemes. Also, technology can be used for monitoring/tracking the uptake of Social protection schemes by the populations. In India, we have effectively used the GIS Enabled entitlement tracking system (GEET) for creating awareness (https://geet.observatory.org.in/#:~:text=Geographic%20Information%20Sys… )

What is the main message on social protection for people with HIV and key populations that should be included in the next Political Declaration on HIV and AIDS?

Comment: The Social Protection measures should be People centric and inclusive and integrated in Nature. As mentioned earlier, it should be holistic and include all the welfare measures for a specific population e.g. Sex workers, Transgenders. 

1. What are the needs and challenges of people with HIV and key populations (in general and for specific populations) and social protection, including in the context of COVID-19, in your country and region?

Most sex workers in the world have been deprived any social protection during the COVID19 crisis because of the criminalisation of sex work. Most governments refuse to recognise sex work as work so they do not provide indemnisation. Even in countries where sex workers can access a legal status, for example as independent workers, many cant access it due to legal barriers such as a lack of documentation for migrants.

Many countries condition any possible support to an « exiting » or rehabilitation program asking sex workers to quit their job. This is not recognised as a « protection » by our communities but rather as a form of blackmail and social control.

Another challenge is that the worldwide ‘rescue industry’ is dominated by Christian groups who use charity as a tool to convert people and divide local communities instead of respecting their needs, especially when it comes to sexual and reproductive health or sex workers’ well-being. The conflation of sex work with trafficking gives an excuse to criminalise sex work and migration instead of protecting people, including the victims of forced labour themselves.

2. Identify and discuss good practices and lessons learned, as well as opportunities for future action in social protection in national HIV responses and in making social protection schemes HIV and key populations – sensitive.  Provide examples from your country and region.

All the good practices come from sex workers’ self organisation. During the COVID crisis sex workers’ organisations around the world have set up fundraising campaigns to provide financial support during the lockdowns, because governments refused to give any money. Once again, sex workers have proven that we were responsible and a key response to another global pandemic by our ability to inform, protect and organise despite being targeted by the police and criminal justice systems. It is a shame that the HIV movement continues to be prejudiced and does not see sex workers as competent enough because we come from socally disadvantaged backgrounds. On the contrary, it would be an opportunity for future action to hire sex workers within HIV organisations to identify the needs and lead in the best responses.

In my country (France), sex workers’ organisations have distributed food parcels and hygiene kits to about 3500 sex workers with the money collected through online fundraising and solidarity between us. Our trade union STRASS helps many sex workers to access the formal economy through its paralegal support team and by helping sex workers to register as self employed/ independent workers. This allows sex workers to access some rights and in the context of the COVID crisis it helped sex workers to access some indemnisation.

In addition, STRASS has organised a collective mutualised contract with health insurance companies so that sex workers can access a better coverage of their medical expenses as well as a scheme to get an income compensation due to sick leaves representing up to 3 months incomes.

3. What is the main message on social protection for people with HIV and key populations that should be included in the next Political Declaration on HIV and AIDS?

Recognise sex work as work and as a legitimate and decent form of labour in the formal economy. Otherwise we will continue to be excluded from social protection mechanisms and/or discriminated agaisnt.

Thanks Thierry Schaffauser -- your final comment re recognition of sex work as legitimate and decent labour resonates strongly. This has been the ask of sex worker movements globally--particularly from large SW Organisations in South and South East Asia. One of the big challenges in sub-Saharan Africa has been organizing sex worker groups--and the uneven laws and policies across the continent in context of sex work. For e.g. a number of ex-British colonies criminalizes the 'work' but not the 'worker' and 'earnings', while South Africa for e.g. criminalizes sex work per se. Again in some Francophone countries there aren't criminalising statues at all... All these have made it hard (not impossible, but hard) for SW groups to organize widely. Of course there sex worker-run organisations in the continent for e.g. in Kenya, South Africa, etc. Thanks.

Yes, I also recommend following the work done by our comrades in Africa https://aswaalliance.org/ and Asia https://www.apnsw.info/ 

Пандемия коронавирусной инфекции еще больше обнажила различные уязвимости людей, живущих с ВИЧ, и людей из ключевых сообществ, в контексте социальной защиты в том числе. И до пандемии нередко жившие за чертой бедности, многие женщины из ключевых групп после введения карантинных мер оказались без средств к существованию. Во время исследования в 2020 году респондентки из каждой страны рассказывали о том, как они не могли обеспечить базовые потребности для себя и своих детей. Многие столкнулись с нехваткой денег даже для приобретения продуктов питания. Наиболее пострадавшая группа – мигрантки, в том числе живущие с ВИЧ, для которых голод также означает невозможность принимать АРВ-терапию. Другой серьезной проблемой стала невозможность оплаты жилья.

Основная причина резкого ухудшения социально-экономического положения – это потеря работы, как в формальном, так и в неформальном секторе экономики. Проблема с работой коснулась и мужчин, и женщин, но последних в большей степени, так как в регионе ВЕЦА именно на них возлагается вся нагрузка по уходу за детьми и работа по дому. Для женщин, переживших насилие, ситуация с потерей работы также чревата риском возвращения в ситуацию насилия. Женщины, затронутые туберкулезом, женщины, вернувшиеся из мест лишения свободы, женщины, употребляющие наркотики, – у каждой из этих групп были свои, сложившиеся задолго до начала пандемии, причины, по которым они не могли официально устроиться на работу. Тяжело складывается ситуация у секс-работниц, и занятых в сфере секс-работы транс-женщин.

Государственная социальная помощь в странах ВЕЦА в начале пандемии была выделена лишь для нескольких категорий граждан. Многодетные семьи, люди с инвалидностью и пенсионеры являются традиционными категориями населения для системы социального обеспечения в регионе.

В Украине, России, Казахстане и Грузии на получение материальной помощи от государства из-за карантинных мер также могли рассчитывать потерявшие работу граждане, официально вставшие на биржу труда. Женщины, живущие с ВИЧ, женщины без детей из ключевых групп не были выделены в категорию нуждающихся в помощи со стороны государства.

Отсутствие системы легальной секс-работы привело к тому, что секс-работницы оказались лишены возможности получать пособие.

Отдельно следует выделить барьеры, связанные с цифровым неравенством. У многих женщин из ключевых групп нет не только навыков, необходимых для того, чтобы зарегистрироваться в системах господдержки, но и компьютеров, мобильных телефонов и доступа к сети Интернет.

Цифровое неравенство влияет не только на доступ к социальной помощи среди тех, кто больше всего в ней нуждается, но и препятствует возможностям женщин получить поддержку сообщества в условиях карантина и самоизоляции.

Небольшой объем пособий там, где они были предоставлены, бюрократические барьеры, а также сам факт того, что женщины из ключевых групп оказались не в приоритете, сделали эту помощь ничтожной. 

Рекомендации исследования "Женщины, ВИЧ, COVID-19 в странах ВЕЦА":

• Государству: выделить женщин с ВИЧ и женщин из ключевых групп в отдельную категорию социально-незащищенных граждан для предоставления адресной социальной помощи;
• Государству: наладить сотрудничество с организациями сообщества с целью сокращения цифрового неравенства и обеспечения доступа женщин с ВИЧ и женщин из ключевых групп к цифровым госуслугам;
• Донорам: предусмотреть финансирование для обеспечения питания и временного жилья для женщин с ВИЧ и женщин из ключевых групп, оказавшихся во время пандемии без средств к существованию;
• Для организаций и сетей сообщества: развивать партнерство с государственными и негосударственными структурами и сотрудничать с ними в целях удовлетворения социальных потребностей женщин из ключевых групп;
• Для организаций и сетей сообщества: включить продовольственную и жилищную поддержку, развитие цифровых навыков и другие услуги в пакеты услуг для женщин, живущих с ВИЧ, и женщин из ключевых групп.

@Amitrajit Saha, thank you very much Piklu, for this excellent summary and for pointing out to existing social protection programs in African countries. It appears that the problems of legal and structural barriers, including the criminalization and exclusion (or, rather “non-inclusion”) of key populations in social protection schemes is paramount and not only in this region. It is also amazing that so much strategic litigation and advocacy are happening. I wonder how one can circumvent the criminalization and lack of recognition of key populations to facilitate social protection coverage? Has this been attempted?

@Yuri Yoursky, an excellent example of how the so-called “anti0-propaganda” laws, while purporting to “protect minors” de facto portray non-heterosexual non-cisgender people and same sex relations as abnormal and exclude such people from society. Do you have any information on key populations other than MSM and transgender people? How about people living with HIV? It was discussed that, because of COVID-19 some countries in the EECA region have abandoned the long-outdated rule of “propiska”, which bounds people to receiving social assistance to their address registration. Do you have more information?

@Chiranjeev Bhattacharjya, this is such an excellent summary of India’s efforts to provide welfare access to transgender people. I know that UNDP and other UNAIDS co-sponsors were actively involved in supporting the efforts, but could you tell us more – what motivated the government to undertake this step? Can it be used for other key populations? I know the change is very recent but when can we expect some analysis of the benefits from this legislation, they would be really helpful.

@Thierry Schaffauser, a very useful summary of the global challenges experienced by sex workers and an interesting example from France. Is my understanding correct that France follows the “end user” model and criminalizes clients of sex workers? If not, what is the current status of sex work? How do sex workers get to unionize, and can this model be used in other countries? It seems to have help achieve important access to some social protection.

@Svitlana Moroz, this is an excellent summary of the situation of women living with HIV, women former inmates, women who use drugs, sex workers, including transgender sex workers in the EECA region. It appears that there is a huge blind spot when it comes to the need of women with HIV in the region and also additional issues related to women who are part of key populations. Clearly the lack of recognition of key populations is a major obstacle but also it is very worrying that women living with HIV were excluded from social protection in many EECA countries. We should raise the question of digital inequality during the Global Dialogue, this is an under-explored theme, but we hear about it more and more.

Yes in France clients are criminalised. We have the right to sell sex but it can't be bought. Don't try to understand the logic. It's just what the lawmakers do. The government claims sex work is a violence against women and should be abolished through (totally inefficient) "exit programs" but we have the obligation to register as independent workers to pay national insurance and taxes otherwise we can be condemned for "hidden/undeclared work". There are local bylaws that ban our presence in public spaces or parking laws against the use of vans and vehicles. There are also third party laws that forbid to rent a place to work, to benefit from our money (so we cant legally use our money...) or any solidarity between us as "helping someone for prostitution" is considered "pimping". This means sex work is legal only if we work in complete isolation, outside, but not in most city centres, generally in remote and dangerous areas and because of banks' discriminations we have to keep a lot of cash on us so that it's easier for people who want to steal our money. Advertising is illegal so we have to use coded expressions and we are regularly cesored in the newspapers or we have to use websites based abroad. Basically everything is done to prevent us from working except for when it comes to giving money to the state. Instead of labour rights and social protection, the governments prefer to fund christian organisations that organise charity and most of the "help" is conditionned to the commitment to quit sex work.  When they find out we lie and continue working they remove the "help" which is much below normal jobseekers' benefits anyway. The government prefers to give money to the prohibitionists' and christians organisations rather than sex workers' organisations because they are afraid that we will give money to "our pimps" or think we are pimps and madams ourselves, since sex workers who refuse to be labelled as victims are then automatically and systematically denounced as "pimps" and therefore as "crime apologists" or "criminals" we are excluded from any serious conversation on sex work. The only funding we may receive is for HIV as the Christians are not good at promoting condom use and talking to sex workers about sex. But then most of the money goes to big mainstream HIV organisations that are controled by white middle class gay men who are mostly clients and never hire sex workers in leadership positions or in decision making roles. The only thing they have to offer is condoms but in the recent years, they told us to eat PrEP so that our clients can have more condomless sex. I guess it's also the reason why WHO want sex workers to take periodic presomptive treatment for chlamydia and gonhorea so that governments dont need to decriminalise sex work or fund access to testing and medical healthcare. We just have to take more pills and shut up.

Our trade union is not recognised as such by the government or the mainstream labour movement but we don't need their approval to exist and to know that we are a trade union. A bit like in the 19th century before the right to unionise existed for other workers. Given that wage earning is illegal we can't have employment rights. So everyone has to be independent, freelance, or to hide the sexual nature of the work, so that it is not defined as "prostitution". Technically, some jobs in the sex industry (in the porn industry for example) can access employment rights but the problem is that most employers prefer sex workers to be independent contractors so they dont pay national insurance for us.

Hello all,

Below is my comment on the three questions:

1. What are the needs and challenges of people with HIV and key populations (in general and for specific populations) and social protection, including in the context of COVID-19, in your country and region?

Persons living with HIV and key populations require an inclusive system that guarantee care and treatment but inadequate social protection coupled with stigma has hindered HIV services. Majority of HIV responses are donor dependent hence prone to disruption incase of unseen circumstances like Covid-19, withdrawal of support or even system inefficiencies. Currently, Kenya is experiencing an acute shortage  of ARVs following a disagreement with USAID(main supplier) who cited corruption and mismanagement of medical supplies within the relevant  Government agency, hence exposing lives of 1.5 million Kenyans living with HIV at risk.

 Social protection programs on the other hand is more weighted  to social assistance which target the most vulnerable in the society  orphaned and vulnerable children, elderly and persons with severe disability but not specific to PLWH and key populations. In addition, there are multiple social assistance programs implemented across different government agencies and most often result into duplication and double dipping owing to a weak coordination framework. Though existing social insurance schemes such as National Health Insurance Scheme is open to all contributors and covers chronic diseases including HIV/AIDS, respective legislations have no specific pronouncement on the vulnerability of PLWHA and key populations. The Covid-19 also exposed a critical gap on the country's  income security floors since workers who lost livelihoods, including PLWHA, were not cushioned from impacts such as malnutrition.

In addition, informality of enterprises in Kenya has hindered uptake of administration of social protection. The informal economy accounts for over 80% of workers, majority of whom have no form of social protection. Informality has also affected establishment of workplace HIV policies which are termed effective in addressing stigma, discrimination and supporting adherence to treatment and care.

2. Identify and discuss good practices and lessons learned, as well as opportunities for future action in social protection in national HIV responses and in making social protection schemes HIV and key populations – sensitive.  Provide examples from your country and region.

The Constitution of Kenya has declared social protection a basic human right for all including persons living with HIV and key population.  Fundamental legislations such as the National Social Security Fund and National Health Insurance Fund Acts were reviewed in 2013 to include informal  and domestic workers, who can participate as individual voluntary contributors.

A social assistance program targeting orphans and vulnerable children in specific regions have been effective in addressing the needs of households affected by HIV/AIDS particularly on nutrition and access to healthcare. Another program dubbed 'Linda Mama' provides for free pre-natal care including HIV testing through the National Health Insurance Fund and has resulted in a decline in mother-to-child HIV transmission.

3. What is the main message on social protection for people with HIV and key populations that should be included in the next Political Declaration on HIV and AIDS?

There is need to accelerate  universal social protection to guarantee coverage of excluded groups such as commercial sex workers, domestic workers and key populations and more importantly, pronounce HIV is a vulnerability which require a specific social protection intervention. Universal social protection will also support reduction of stigma and enhance uptake of HIV services excluded groups. 

Damaris Muhika , many thanks for your contribution! Important issues, indeed - how to coordinate a national system that is not sufficiently robust and make it more agile and inclusive. You are also capturing the impact that COVID-19 has had and could potentially have, including on access to nutrition. Another important issue that you raise is how to provide coverage for the informally employed - on one hand, in conditions of high informal employment in the country and on the other, taking into account that many key populations are informally employed. Are there any private, ro donor-supported schemes in Kenya that focus on key populations - e.g. conditional cash transfers, food and service assistance? Please advise - and many thanks again!

Dear all,

My response to the first question - challenges PLHIV and key populations face -  is as follows: 

The ILO research -  “Access to and effects of social protection on workers living with HIV and their households” - showed that even when policies do not exclude people living with HIV, they face challenges in accessing the existing social protection service.

Three main challenges are as follows:

• lack of adequate knowledge about the programmes;
• complicated procedures for accessing the existing social protection programmes; and 
• stigma and discrimination.

With the possible exception of medical services (ART), social protection access for PLHIV and key populations is wanting. Out- of- Pocket expenses for accessing health services are huge and access to health insurance is limited. PLHIV and key populations, who often work in the informal economy don't normally have access to a secured income due to precarious nature of their jobs.

 Challenges posed by COVID-19:

Covid-19 exacerbated existing inequalities and had an adverse affect on PLHIV and key populations, as captured in the ILO policy brief -  COVID-19 and the world of work: A focus on people living with HIV. Main issues are as follows:  

- Almost 1.6 billion informal economy workers in the world were significantly impacted by lockdown measures. This affected PLHIV as well, majority of whom work in the informal economy.

- The COVID-19 crisis, and associated school and day care closures, reduction in public services for people with disabilities and the elderly, the non-availability of domestic workers and the need to look after family members with COVID-19 has increased the unpaid care burden, including for people in HIV-affected households.

- HIV prevention and testing services have also slowed down. Those who test positive for HIV may not access ART immediately because health facilities are fully engaged in dealing with the COVID-19 emergency.

- The majority of people living with HIV do not have adequate access to social protection. With limited access to unemployment insurance and income support, the impact of the COVID-19 crisis  was particularly harsh on all groups in vulnerable situations, including PLHIV.

- COVID-19 led to increased risk of violence and harassment, particularly gender- based violence for PLHIV and key populations.

Afsar, Syed Mohammad  , thank you for this important contribution and for sharing the publications of ILO on PLHIV and social protection and CIVID-19 and PLHIV and key populations. You raise several very relevant topic, as far as understand, and please correct me if I have misinterpreted your input.

Few social protection schemes take into account the needs of PLHIV and even fewer of key populations. However, as you point out, even those who do often entail such complicated procedures and provide so few information that they are de facto not accessible. In order for social protection schemes to be acceptable for PLHIV and key populations, they have to be transparent and accessible.

Like many other respondents you point out that stigma and discrimination are major impeding factors for access to social protection even where it is provided to PLHIV and key population. In order for social protection schemes to be acceptable, they have to be stigma- free.

The question about social protection for the workers in the informal economy raised by Thierry Schaffauser , Nataliia Isaieva, Damaris Muhika and many other respondents is posed here again - in order for social protection schemes to work for PLHIV and key populations they have to be covering people in the informal economy. The situation has been aggravated by the impact of COVID-19 on the informal economy and, consequently, people living with HIV and key populations. To me it seems like we should be discussing this nexus and possible solutions here in the e-discussion and at the global dialogue and also the return on investment such protection schemes would yield.

Thank you again for your contributions!

Dear all, thank you for a very interesting discussion.

What are the needs and challenges experienced by people living with HIV and key populations and social protection, including in the context of COVID-19?

To be specific in answering this question, I’d like to refer to the results of a study led by the Eurasian Women’s Network on AIDS (EWNA) and supported by UNDP, UNFPA, and UNAIDS. The study was designed in April 2020, at the early stage of the COVID-19 pandemic. The study targeted women that were least protected by state systems of social support: women living with HIV, sex workers, transgender women, and women who use drugs in ten countries of Eastern Europe and Central Asia. Many women from key populations lived below the poverty line even before the pandemic. With the start of lockdowns, they couldn’t continue with their usual economic activities. They didn’t have money to buy food and to pay rent. Risks of starvation and homelessness overshadowed health needs. It was hard to keep HIV prevention and treatment and sexual and reproductive health services as a priority, in the light of catastrophic economic situations of women with HIV and women from key populations.

So the study has shown - once again - that we can’t separate health needs from social protection needs.

However, access to social protection services among women living with HIV and women from key populations during the COVID-19 pandemic was very low. Many of them didn’t have ID cards (паспорта) or other papers to apply for social assistance. Sex workers couldn’t prove that they’ve lost their jobs because sex work was not legal. Many women living with HIV and women who use drugs couldn’t get formal employment because of stigma. As a result, they were not entitled to unemployment benefits. Another big issue was a lack of equipment and skills to register online in government support systems.

What are the good practices and lessons learned and opportunities for future action in your country and region in incorporating social protection in national HIV responses and in making social protection schemes HIV and key populations – sensitive?

The region of Eastern Europe and Central Asia is home to many strong community-led initiatives with years of experience providing HIV services to women from key populations. When the pandemic began, community networks stayed in touch with these women, monitored not only their health needs but also their social needs, and provided support. In many cases, it was direct support - food packages, infant formula, transport to clinics, and the distribution of HIV medication. They had to re-budget their programmes to find money to procure food for their clients in need. It was a hard choice to make between HIV services, advocacy, and addressing social needs during the time of COVID-19.

Community engagement in the direct provision of social assistance and in advocacy for social protection is definitely a good practice. However, the reorientation of community-led organizations towards social protection should not happen at the cost of HIV prevention and human rights advocacy. Community-led social protection-related work needs to be adequately budgeted. In some EECA countries, this would require international donor support. There is also a need for technical assistance on community-led monitoring of social protection and on advocacy for governmental solutions focused on women from key populations.

Thank you Dasha Ocheret  for this contribution. Would it be possible to share a copy of the study you mention with the participants in our e-discussion? Thank you for bringing up an important intersectional issue - the particularly difficult situation of women living with HIV and women of the key populations.

Another important matter is the documentation, or the lack thereof and the implications that it has for accessing services, including social protection.

This is perhaps the third, or fourth time the issue about the unnecessary complexity of access to government social protection services resurfaces - it appears that such complex digital services de facto exclude people with HIV and key populations and especially those who do not have access to digital devices and/or are not web-savvy.

Lastly community engagement is extremely important and community leadership in providing/ facilitating the provision of social protection is a topic that we expect to explore further in this discussion and the global dialogue. Many thanks again!

Dear All, thank you so much for this excellent start of the discussion! Before I forget, please remember that we also have a Dialogue coming on 18-19 May and in case you haven't registered yet, please register and send to others!

It is impossible to capture the richness of the discussion so far but to quickly summarize we have had very interesting debates on structural and legal frameworks that hinder social protection of people living with HIV and key populations, funding constraints, unnecessary complex bureaucracy.Stigma and discrimination are major impeding factors in social protection as well. Interesting to see more positive examples coming from the Global South than from the Global North, especially with the laws and policies on transgender welfare in India.

Clearly voices of communities are often not heard and social protection services, where available, are not necessarily acceptable. COVID-19 has been a wake up call also in revealing how unprotected the general population is and especially how vulnerable people with HIV and key population - including women of key populations can be.

As I pass the baton of the moderator to my ILO colleague Diddie Schaaf  I hope that we can hear more from communities of people who use drugs, transgender people, former inmates - and that we can cover more Latin and South America and the Caribbean - and for this we also relay on Diddie's experience in this region.

Please encourage others to join and comment!

Lastly, in an effort to provide a summary of the buzz words so far at a glance I created a word cloud image that I would like to share with you. Once again many thanks for your excellent input!

Q2: Identify and discuss good practices and lessons learned, as well as opportunities for future action in social protection in national HIV responses and in making social protection schemes HIV and key populations – sensitive.  Provide examples from your country and region.

Some years back, UNDP in Asia worked on ‘HIV-sensitive social protection.’ We advocated HIV-sensitive social protection as an approach to integrate HIV-relevant considerations into existing general social protection policies and schemes.

In broader terms, HIV-sensitive social protection also includes creating ‘enabling environment’ such as structural, transformational and social changes through amending laws and administrative procedures.

Enabling environment aims at reducing barriers for people living with or affected by HIV (‘key populations’) to engage in, access and benefit from social protection policymaking, schemes and opportunities.

HIV-sensitive social protection contrasts with ‘HIV-specific’ social protection, which is designed exclusively for key populations (e.g. ART services). Compared with HIV-specific social protection, HIV-sensitive social protection has the potential to be more inclusive, perhaps more sustainable and more equitable, as it leverages general social protection schemes, policies and systems.

While both HIV-sensitive and -specific social protection have their own strengths and weaknesses, we need both to cover different aspects and the unique and varying needs of key populations and to maximize their social, economic and rights protection.

There are several ways to make social protection ‘HIV-sensitive.' One way is to modify the eligibility criteria in favour of key populations. This includes removing HIV-based exclusion criteria. Another way is to incorporate HIV-sensitive services or considerations into existing social protection, laws, policies or schemes.

I want to share some examples of HIV-sensitive social protection from Asia (Some examples may be outdated, but they can still provide useful insights in my view. You can find more details in the reference section at the end).

(1) Add HIV-sensitive considerations to official identification documents or legal recognition.

Having proper ID documentation enables transgender people to access social protection and other services such as healthcare, legal counselling, opening a bank account, and voting.  It could also reduce the risk of transgender persons being questioned, harassed, detained, or denied services because of the difference between what the ID says and how they look.

• The Bangkok Metropolitan Administration changed an ID photo/dress code policy to allow transgender people to be photographed in their chosen gender/appearance rather than the sex assigned at birth for their national ID cards.

• The Supreme Courts of Nepal and Pakistan issued an order to include a third gender category in official documents, including the national ID card. Similarly, India, Nepal and Pakistan added a third gender category in the passport and the census. The census reform allowed transgender persons to become part of the official statistics for social recognition and visibility and enabled policy discussions on transgender issues, including social protection. (E.g. A number of state governments in India, for example, established a mechanism such as ‘a Transgender Welfare Board’ specifically designed to assist the transgender community with social protection schemes and their legal rights.)

(2) Incorporate HIV-sensitive considerations into existing general social protection schemes/processes

• A pension scheme for widows in one Indian state had a minimum eligibility age of 40 years old. However, many widows living with HIV tended to be much younger, and therefore they could not access this scheme. Through advocacy by positive networks, the minimum age for HIV-affected women was relaxed from 40 to 18. Consequently, a much greater number of HIV-affected widows were able to access this scheme. The change also benefited other young widows.

• There were social protection schemes designed for below-the-poverty-line (BPL)  households, also in one state in India. The eligibility criteria were modified to give a conditional below-the-poverty-line status to people living with HIV, which allowed them to access certain social protection schemes such as food subsidies and healthcare. 

• There was a government health insurance scheme in India for informal workers, which initially excluded people living with HIV. However, this HIV exclusion was later removed.

• In Cambodia, people living with HIV were included as a special vulnerable group in the country's first social protection strategy, based on the evidence of their socio-economic vulnerabilities from UNDP’s study. Subsequently, the government decided to give an additional weight (point) for HIV-affected households (along with other vulnerable groups such as persons with disabilities) in the methodology to identify households eligible for social protection schemes such as free healthcare and scholarships.
  
  To address outreach and confidentiality, the government also allowed representatives of HIV positive networks to be involved in all stages of the survey process, which later expanded to include other key populations, including transgender, sex worker, and drug user representatives. Furthermore, as part of COVID response, the government also included HIV-affected households in its cash transfer initiative.

• Thailand has unique, sensitive policies to facilitate health service utilization by people living with HIV, as well as to enable the participation of marginalized communities in UHC decision-making processes. For example, people living with HIV are provided with a unique ID number different from the Citizen ID number to protect confidentiality. They are also allowed to access health care facilities outside their registered locality so that they can avail HIV-related services without the fear of being seen by friends or neighbours.
  
  The governing body of Thailand's universal health coverage allocates four seats (out of 30) to civil society representatives, which include the community of HIV-positive people/key populations.

While HIV-sensitive social protection has challenges, particularly the confidentiality issue and complex procedures, the engagement of community networks can help address these challenges.

It can also provide an opportunity to inform social protection policymakers and service providers of the importance of confidentiality and the unique challenges faced by key populations. 

HIV-sensitive social protection could provide new, innovative approaches to integrate greater equity and the unique needs of key populations within the context of social protection. Consequently, it could enhance the coverage/targeting, access and effectiveness of social protection as a whole.

Furthermore, HIV-sensitive social protection could potentially pave the way for similar sensitive approaches to benefit other marginalized and highly-vulnerable populations such as persons with disabilities, ethnic minorities, and slum residents, in line with the SDG principles of ‘leaving no one behind’ and ‘reaching the furthest behind first.’

Our experience suggests the following factors as critical in advancing social protection for key populations: (1) credible data/evidence of disproportionate socio-economic impacts on key populations and (2) strong community engagement. These two factors are still relevant today and need to be incorporated into COVID-19 responses and social protection discourse. 

Q3. What is the main message on social protection for people with HIV and key populations that should be included in the next Political Declaration on HIV and AIDS?

We organized an Asia-Pacific regional consultation on HIV-sensitive social protection in partnership with PLHIV networks, government representatives and UN partners (ILO, UNAIDS and UNICEF). The consultation came up with the following 5 principles, which I believe are still relevant in principle: 

1. Aim for HIV-sensitive social protection rather than HIV-specific social protection: For reasons of sustainability, coverage, involvement of multiple sectors and the opportunities for mainstreaming HIV into national and decentralised development plans.

2. Involve multiple sectors and partners: HIV-sensitive social protection requires the involvement of different ministries, the private sector, civil society and communities. Their involvement and partnership are required at every stage - from planning to implementation. This is also important for sustainability.

3. Engage affected individuals, networks and communities, especially key populations: Design of HIV-sensitive social protection programs should be inclusive and participatory so as to ensure that the interventions address the specific needs and concerns of the affected people.

4. Protect and enhance human rights: While implementing HIV-sensitive social protection schemes, special attention must be paid to ensure that the human rights of the participants are not violated but rather are enhanced. Issues of concern are mandatory testing, disclosure of beneficiary details, breach of confidentiality and involuntary confinement.

5. Take into account sustainability: As in the case of ART, HIV-sensitive social protection requires long-term political and financial commitment, and hence sustainability should be an integral part of the planning process.

Related UNDP publications:

• HIV-Sensitive Social Protection for Impact Mitigation in Asia and the Pacific - Report on the High-level Technical Consultation
• HIV Sensitive Social Protection: A review of Cambodia’s social protection schemes for incorporating HIV sensitivity
• Case study: Cambodia’s HIV-Sensitive Social Protection in “Getting to the Last Mile in Least Developed Countries” (pages 22-26)
• Embedding Equity in Universal Health Coverage Schemes: Lessons Learned from Thailand
• HIV-Sensitive Social Protection in India
• HIV-Sensitive Social Protection: A Four State Utilisation Study
• The Socio-Economic Impact of HIV at the Household Level in Asia: A Regional Analysis
• The Socio-Economic Impact of HIV at the Household Level in Asia: A Regional Analysis of the Impact on Women and Girls
• The Socio-Economic Impact of People Living with HIV at the Household Level in Myanmar

Allow me to begin by commending this e-consultation, and the opportunity to hear from communities on the frontline. COVID-19 has demonstrated yet again the importance of equitable and rights-based responses, and the pitfalls of leaving people behind. Social protection is an important enabler of healthy lives for all, and meaningful engagement of communities in shaping and delivering services is necessary to ensure they are accessible and acceptable. 

1. What are the needs and challenges of people with HIV and key populations (in general and for specific populations) and social protection, including in the context of COVID-19, in your country and region?

Global Fund has been using grant flexibilities and C19RM to support countries to mitigate the impact of COVID-19 on programs to fight HIV, TB and malaria, and initiate urgent improvements in health and community systems. Across countries and regions we have seen how food insecurity has compromised adherence even where multi-month dispensary of drugs and home deliveries made those available. We have seen - and intervened to end - discriminatory social protection practices leaving some populations behind. Inability to access social protection due to fear of stigma, or disclosure of confidential information, are all barriers compromising effectiveness of existing social protection mechanisms. The Global Fund guidance on human rights in times of COVID-19 provided GF implementers with a frame for adjusting delivery of programs to reduce human rights-related barriers: https://www.theglobalfund.org/media/9538/covid19_humanrights_guidanceno…;

2. Identify and discuss good practices and lessons learned, as well as opportunities for future action in social protection in national HIV responses and in making social protection schemes HIV and key populations – sensitive.  Provide examples from your country and region.

There are multiple promising good practices emerging from community-led responses, including to COVID-19. It is important that those are documented, and communities appropriately resourced, and community systems continuously strengthened. The mid-term assessments underway as part of the Global Fund Breaking Down Barriers initiative are documenting important scale up of programs to reduce human rights-related barriers, examples of resilience of such programs, and importance of joint coordinated actions of partners - government, civil society and donors alike - for comprehensive responses. Together with Frontline AIDS, Global Fund has developed a guide for implementers, to support them in scaling up programs to reduce human rights barriers: https://www.theglobalfund.org/media/9731/crg_programmeshumanrightsbarri…;

The lessons learnt in terms on ensuring quality of human rights programs have informed the Global Fund guidance: https://www.theglobalfund.org/media/9729/crg_programstoremovehumanright…

3. What is the main message on social protection for people with HIV and key populations that should be included in the next Political Declaration on HIV and AIDS?

Commitment of Member States to achieving the societal enabler targets, and to comprehensive programs to reduce human rights-related barriers to health and social protection, including through increased domestic funding and stronger accountability, would represent an important starting point and platform for subsequent joint programmatic work and advocacy.   

Thank you very much Kazuyuki Uji for providing in-depth responses to questions 2 and 3. All the specific examples, references and links you have included, are of great value for this discussion.

The broad definition of HIV-sensitive social protection you are providing, including creating an enabling environment to reduce barriers, is very useful and addresses the previous comments we have received on the difficulties in accessing social protection schemes and opportunities.

In brief, the points you are making from the examples you are giving from Asia are:

1. Add HIV-sensitive considerations to official identification documents or legal recognition (mainly for transgender populations)
2. Incorporate HIV-sensitive considerations into existing general social protection schemes/processes to tackle barriers people living with HIV are facing.

Furthermore, from your experience at UNDP you include the following factors that are critical in advancing social protection for key populations: (1) credible data/evidence of disproportionate socio-economic impacts on key populations and (2) strong community engagement (and the need to be incorporated into COVID-19 responses and social protection discourse). 

With regard to the Political Declaration the prioritisation of HIV-sensitive social protection, the involvement of a broad array of national stakeholders, the meaningful engagement of people living with HIV and key populations, the protection of human rights and the quest for sustainability are all very critical elements of the way forward. HIV-sensitive social protection requires long-term political and financial commitment.

One question that came to mind, in the COVID-19 context and with countries receiving resources for social protection and resilience programmes, how can the joint programme and the global HIV community best tap into these resources to benefit people living with HIV and key populations? Are there any lessons learned?

1. What are the needs and challenges of people with HIV and key populations (in general and for specific populations) and social protection, including in the context of COVID-19, in your country and region?

People with HIV and/or key populations are not counted in the populations groups that receive social protection, because those programs are very limited and stigmatized and used for political outcomes; so they are not based in a socioeconomic analysis of needs, but in the interests of political parties. In the context of the COVID-19 pandemic, we were not even counted as part of the people living with chronic diseases. The small social protection programs in Bolivia, my country, were directed for pregnant women and families with children in school age and elders were also included. Politically HIV is not even a priority, and less in the context of a pandemic.

2. Identify and discuss good practices and lessons learned, as well as opportunities for future action in social protection in national HIV responses and in making social protection schemes HIV and key populations – sensitive.  Provide examples from your country and region.

A good practice is what communities have been doing. Across Latin America, I know communities of people with HIV, sex workers and transgender women, organized volunteer work for collecting and distributing food. Of course these initiatives had no funding; these were based in the strength of communities and the need to respond to the increasing levels of poverty which led to a survival status during the pandemic. These experiences led by communities are very important but in order to continue, will need legal and financial support.

3. What is the main message on social protection for people with HIV and key populations that should be included in the next Political Declaration on HIV and AIDS?

The need to invest in HIV community led responses, as was stated in the Political Declaration, especially in humanitarian context like the COVID-19 pandemic, where the public health system collapsed but communities remained resilient next to its constituents.

1.Каковы потребности и проблемы людей с ВИЧ и ключевых групп населения (в целом и для конкретных групп населения) и социальной защиты, в том числе в контексте COVID-19, в вашей стране и регионе?

Попробую ответить на этот вопрос в контексте проблем одной из ключевых групп - сообщества секс-работников России.
Секс-работа в России наказуема. Это административное правонарушение. За нее накладывают не большой штраф, но проблема не в штрафе. Проблема в том, что секс-работники боятся огласки из-за огромной стигмы и дискриминации, которой они подвергаются. Когда человека привлекают к административной ответственности, информация об этом попадает в банк данных МВД и хранится там вечно. И если другие нарушения не особенно влияют на жизнь человека, то тот факт, что человека наказывали за проституцию, негативно влияет на всю его дальнейшую жизнь. Были факты, когда бывшим секс-работникам отказывали в приеме на работу из-за того, что несколько лет назад их наказывали за проституцию. Есть факты увольнения или принуждения к уходу с официальной работы людей, которые в свободное время оказывали секс-услуги. Студентов могут отчислить из Университета. Также был факт, когда сына секс-работницы отказались призвать в элитные войска из-за того, что его мать много лет назад наказывали за проституцию.
По законам России, если родитель несовершеннолетнего ребенка занимается проституцией, то такую семью ставят на особый контроль, постоянно проверяют, предают огласке род занятий родителя. Часто, при решении вопроса о лишении или ограничении родительских прав, суды расценивают факт занятия проституцией матерью, как ее плохую характеристику и отдают ребенка отцу. И этим отцы часто шантажируют своих бывших жен, угрожают забрать у них детей.
Из-за того, что секс-работа в России наказывается, секс-работники не могут говорить о ней открыто, и не могут получить доступ к правосудию. Потому что если клиент причинил секс-работнику вред, то в полиции сначала накажут секс-работника за проституцию, а потом, возможно, примут заявление о преступлении. Поэтому секс-работники очень редко обращаются за помощью в полицию. В тех редких случаях, когда удается возбудить уголовное дело и довести его до суда, приговоры бывают обычно более мягкими по сравнению с другими, где потерпевшим был не секс-работник.
Когда суды принимают решение о наказании человека за проституцию, очень часто это делается без всяких доказательств его вины, только по личному признанию. Это признание вины секс-работников, силой и угрозами заставляют писать в полиции.
Секс-работники никак не защищены от насилия. Государство не признает секс-работников особой социальной группой, поэтому преступления в отношении них, формально не считаются преступлениями ненависти.
Из-за криминализации всех аспектов секс-работы, люди, которые оказывают секс-услуги не могут получать полноценную медицинскую помощь, потому что боятся говорить врачам о своей работе. .Были факты, когда секс-работница сообщала врачу-гинекологу о своем роде деятельности и врач после этого делал осмотр в грязных перчатках и грязными инструментами, при этом унижала секс-работницу словами. Она говорила: - "В тебя и не такое запихивают".
В таких условиях ни о какой социальной защите секс-работников на государственном уровне говорить нельзя. В период пандемии, секс-работникам пришлось сложнее, чем многим другим людям, которые имели официальную работу и сохраняли свой заработок в период карантина.
У кого были сбережения, тот мог себе позволить не работать 1-2 месяца. Но такая возможность была не у каждого. А за нарушение карантина были введены огромные штрафы. Поэтому некоторая часть сообщества секс-работников откровенно нуждалась в продуктах питания и в средствах для оплаты жилья.
Государство в период пандемии выдавало некоторые пособия для семей с детьми. Был упрощен порядок получения статуса безработного. Форум секс-работников обучал сообщество, как и какими льготами и пособиями можно воспользоваться, но это были пособия для общего населения, не для секс-работников. Получить статус безработного тоже оказалось не так просто, как обещали. И пособие по безработице было настолько маленьким, что секс-работники предпочитали рисковать и продолжали оказывать секс-услуги.
То есть, в России из-за криминализации секс-работы, секс-работники как социальная группа не имеют доступа ни к каким государственным социальным программам.
 

2. Выявить и обсудить передовую практику и извлеченные уроки, а также возможности для будущих действий в области социальной защиты в рамках национальных мер борьбы с ВИЧ и сделать схемы социальной защиты чувствительными к ВИЧ и ключевым группам населения. Приведите примеры из вашей страны и региона.

После того, как мы пережили две волны пандемии, можно сделать некоторые выводы о том, какие можно извлечь уроки.
Важный урок - секс-работники, и все население в целом должно иметь точные знания о той социальной помощи, которую можно получить и знать механизм получения такой помощи.
Другой урок: разовые, точечные акции помощи отдельным членам сообщества не могут решить проблему в целом. Государство должно признавать все существующие группы населения и профессии и считать их равными другим группам и профессиям. Значит, или давать возможность секс-работникам продолжать работать с соблюдением необходимых мер безопасности, либо давать им средства на жизнь в период запрета на работу.
Мы не говорим об обязательной бесплатной вакцинации секс-работников, потому что в России существует большое недоверие к вакцинам от КОВИД-19. И не все секс-работники хотят получить эту вакцину. Но для желающих секс-работников, должна быть такая возможность в числе первых. Особенно это касается секс-работников-мигрантов.

Alexandrina Iovita : Thank you for pointing out the response the Global Fund is giving to the COVID-19 pandemic and for mentioning that COVID-19 has caused additional barriers for people living with HIV and key populations to access social protection programmes. As you state, the inability to access social protection due to fear of stigma, or disclosure of confidential information, are all barriers compromising effectiveness of existing social protection mechanisms. I would like to highlight your point on the documentation of best practices and especially of joint coordinated actions of partners - government, civil society and donors alike - for comprehensive response.

Violeta Ross, thank you so much for your contributions. The point you are making on social protection programmes being limited, stigmatized, not based on a needs assessment and used for political outcomes is very relevant, as it focuses on both the difficulties in accessing these programmes for people living with HIV and key populations, as well as for the population in general. You mention as well that in the context of the COVID-19 pandemic, in Bolivia, people living with HIV were not included as part of the group of people living with a chronic disease, therefor limiting access to protective measures against COVID-19.  

Мариям Абишева highlights the special situation of sex workers in the Russian Federation. Sex work is criminalized and even though it is an administrative offense with not very high fines, the stigma and discrimination surrounded by sex work are worse. Violence and harassment against sex workers are not considered hate crimes and access to medical care is complicated because of the stigma and discrimination. A legal barrier such as the criminalization of the behaviours of key populations are one of the first barriers in accessing any services, including social protection programmes. Thank you for the important points your are raising. 

Violeta Ross indicates that social protection programmes are very limited, and Alexandrina Iovita mentions governments and donors as important partners in a comprehensive response. Any experiences and good practices contributors can share on financing of social protection programmes, would be very much appreciated.

Thank you colleagues for this interesting discussion. Sharing some key messages from the Focus Group Discussion for the new UNAIDS Strategy that speaks to some of the issues raised and need to be addressed. The full report is attached.

Message 1: COVID-19 has made it evident that social protection uniquely addresses the needs of the most vulnerable people. Many of these schemes are implementing support that mitigates the impact of HIV and helps reduce HIV risk. UNAIDS should leverage these programmes, partnerships, and linkages to maximize the support provided to marginalized and affected populations. 

Message 2: Social protection is a game-changer for the COVID-19 response and an accelerator of the HIV and AIDS response. 

Message 3: The COVID-19 pandemic, as with other health crises, has exposed existing inequalities and disproportionately affected people already criminalized, marginalized and living in financially precarious situations, often outside social protection mechanisms such people living with HIV, women, children, adolescent mothers, men who have sex with men, trans people, sex workers, people who inject drugs, people in prisons, migrants, etc. 

Message 4: The notion that social protection is a budget and expenditure item that countries often think they cannot afford is being replaced by the perception that it is an investment in building resilience. 

Message 5: If in 2016, Absent COVID-19, the 2016 Political Declaration prioritized social protection as one of the ten targets of the UNAIDS Strategy 2016-2021, the advent of COVID-19 and the overwhelming demand for social protection systems and more resilient systems for health must only inspire us to prioritize it even higher. 

Read the HIV and Social Protection Focus Group Report here

 @Мариям Абишева Thank you for your views on the second question, from the experiences of COVID-19 you mention that the entire population should have knowledge about the kind of social assistance that is available and what the mechanisms are to access this. Another lesson from COVID-19 you mention is that social protection should be structural, not one time, and all population groups and professions should be included equally.

David Chipanta : Thank you for your 5 key messages that highlight that COVID-19 has made it evident that social protection is uniquely positioned to address the needs of the most vulnerable people and that it is a game changer for COVID-19 and an accelerator in the response to HIV. Related to your 4th message: The notion that social protection is a budget and expenditure item that countries often think they cannot afford is being replaced by the perception that it is an investment in building resilience. This is a key message, we would welcome comments, recommendations and lessons learned from all participants regarding the finance and sustainability side of social protection. David Chipanta : any lessons learned that you can share?

1. What are the needs and challenges of people with HIV and key populations (in general and for specific populations) and social protection, including in the context of COVID-19, in your country and region?

The needs and challenges of people with HIV and key populations on social protection cannot be overemphasized. The unprecedented COVID-19 pandemic has only exposed the gravity of inadequate social protection particularly in Africa where only 17.8% of the population is covered by at least one form of social protection programme as per the World Social Protection Report, 2019. I will respond to the question in reference to Kenya where majority (84%) of the labour force fall within the informal economy which is also the category where many people with HIV and key populations work. The informal economy is regarded as the ‘missing middle’ as they are barely benefitting from social assistance programmes or contributory social protection schemes leaving them exposed to risks. There has been attempts to extend social protection to the informal economy workers but this has barely scratched the surface. Many informal economy workers are still not enrolled with the National Hospital Fund and lack income security for their children and in old age and even as working age populations they remain exposed to contingencies as they lack key benefits such as maternity, sickness, work injury and illness and unemployment benefits either because they are not provided for in the existing social security schemes or they face challenges in contributing to the schemes. There is therefore need to increase the coverage in terms of numbers and adequacy to cater for all workers but in particular those in the rural and informal economy as they have been left behind. Assessing the different dynamics that pose challenges to people with HIV and key populations to access social protection such as stigma and discrimination, punitive laws, lack of information, contributory capacity, inflexible schemes, documentation is key as it will enable appropriate measures to be put in place. 

Where social assistance and cash transfer programmes are not universal, the targeted approach poses administrative challenges with high exclusion errors and people with HIV and key populations have a higher probability of being excluded from the programmes due to stigma and discrimination amongst other factors. Even when programmes are universal lack of information and registration requirements may still hinder access.  

HIV and key population programmes are heavily externally funded at 80%. The introduction of universal health coverage (care) has been a good step in the right direction in Kenya but it should ensure that essential health services to include ARVs, treatment for opportunistic infections and primary health care for people with HIV and key populations is integrated in UHC as this will lead to enhanced country ownership of the programmes and sustainability.   

2. Identify and discuss good practices and lessons learned, as well as opportunities for future action in social protection in national HIV responses and in making social protection schemes HIV and key populations – sensitive.  Provide examples from your country and region.

In Kenya, the Cash Transfer Programme targeting Orphans and Vulnerable Children (OVC) has been a good practice that still needs to be highlighted as its introduction in 2004 provided a safety net for many children orphaned as a result of HIV. The programme has over the years catered for the nutritional requirements of the children, ensured retention of the children in schools and increased their access to healthcare. However, as the children transition into adulthood further support is required as many are still in schools as they turn 18 years and there is a gap in supporting the school to labour market transition that still needs to be filled to break the cycle of poverty. The transfer values remain low at USD 2 per month and they required to be reviewed to respond to inflation.

3. What is the main message on social protection for people with HIV and key populations that should be included in the next Political Declaration on HIV and AIDS?

The main message for inclusion in the HLM Political Declaration on HIV is that access to social protection is a fundamental right that should be accessible to all including people with HIV and key populations which should be captured at policy level and in practice. Our experience in practice is that even where there are universal social protection programmes and the right to social protection is enshrined within the legislation, people with HIV and key populations are being left behind which is attributable to the fact that many still lack adequate knowledge on existing social protection programmes and registration processes, lack of required documentations, punitive laws that lock out key populations from enjoying their rights to accessing services and social protection, stigma and discrimination which bars them from benefitting from existing social protection programmes among other factors.   Addressing these factors will enable people with HIV and key populations to be covered by social protection programmes. A sustained momentum is required to ensure for comprehensive social protection programmes for all in order to attain the SDG targets by 2030 through a rights based life cycle approach. Shock responsive social protection systems need to be strengthened and adequately financed to cushion all and particularly those who face the danger of being left behind under normal circumstance and in crisis situations.  

Blend of questions 2, 3 and 4.

Hi all, it has been a pleasure to read this insightful discussion!

Social protection for people living with HIV and key populations most at risk of HIV is critical for a just and sustainable COVID-19 response and recovery – one that lifts up those who are vulnerable and marginalized in greater measure than the pandemic has set them back. Without this, talk of building forward better and rejecting the status quo, risks being just that - talk.

Strengthening and integrating the social safety nets built on the fly during the pandemic, and sustaining these on the path back to the SDGs, is a major opportunity to support critical HIV-related needs. Socio-economic impact assessments and national socio-economic response plans could reveal strong entry points for HIV-COVID planning, alignment and integration, including in the context of social protection and making optimal use of the resources being released to recover from the impacts of pandemic.

With domestic financing now accounting for over half of available financing for the global HIV response, and needing a strong boost alongside international assistance, it is critical to support countries to achieve efficiencies, including by allocating limited resources towards the most effective interventions or to focus resources strategically by location or population. Supporting innovative ways to expand domestic resource space is also critical. A few thoughts:

• Debt standstill can create fiscal space for investing in the AIDS response, including HIV-sensitive social protection, and we should continue to advocate for the concerted and collaborative international approach needed to make this happen. UNDP’s recent report finds that a monthly investment of just 0.07 percent of developing countries’ GDP could provide temporary basic income to help the world’s poorest women cope with the effects of the pandemic.
• It is more important than ever to identify and efficiently finance high impact and integrated solutions, especially considering the urgency of socio-economic impact mitigation and the need to make up lost ground on the path back toward the SDGs. Through the UKRI GCRF Accelerating Achievements for Africa’s Adolescents (Accelerate) Hub, UNDP is working with academic, UN, government and donor partners, as well as young people to identify the service combinations – spanning social protection, nutrition, health, schooling, employment, gender equality and safety – which best help adolescents in Africa to reach their potential. Work by UNDP and the STRIVE consortium at the London School of Hygiene & Tropical Medicine, with support from the Government of Japan, has shown how financing across sectors of high impact solutions can make them cost-effective investments of scarce resources.
• Sugar, alcohol and tobacco taxes (STAX) are an important and underutilized tool to improve health, avoid the costs of poor health, and increase domestic resources for health and development, including for UHC and other social protections. Worldwide, increased STAX could avert 50 million premature deaths and raise US$20.5 trillion in revenue over the next 20 years. Uganda uses alcohol taxes to help finance its HIV response, to reduce reliance on external donors. The Philippines uses additional revenue from taxing health-harming products to improve the accessibility, affordability and quality of health care in the country, including for HIV. Several other countries are leading the way.

Finally, I have seen (and written) quite a bit on how COVID-19 has exposed and exacerbated inequities, and rightly so. But the pandemic has also revealed the extraordinary capacity of people living with HIV to step up in this time of crisis. I am thinking of examples like in Djibouti, where women living with HIV are manufacturing PPE to protect each other and society, with UNDP’s support. It is time we all step up and do the same for them. I would like to see notions of reciprocity, justice, fairness and equity appearing strongly in the next Political Declaration on HIV and AIDs.

Annette Verster  mentions the importance of the participation of key populations in these discussions as well as getting their needs reflected in the political declaration. The WHO guidance on key populations includes the revision of laws and legislation that criminalize or discriminate people based on their behaviour as an enabling factor. Thank you for your contributions.

Hellen Magutu  highlights the specific situation of informal work (85% of the labour force in Kenya). This is also the sector where many people with HIV and key populations work and which was hard hit by the COVID-19 pandemic. The challenges around the informal sector were previously mentioned by Afsar, Syed Mohammad  , Thierry Schaffauser , Nataliia Isaieva , Damaris Muhika and other contributors. 

Hellen Magutu also mentions country ownership; universal health coverage is a good step in the right direction in Kenya as long as it includes all essential health services for people with HIV and key populations. The Cash Transfer Programme targeting Orphans and Vulnerable Children in Kenya is also a good practice. This programme could provide important experiences for extending social protection to people living with HIV and key populations.

The main message you give for inclusion in the HLM Political Declaration is that access to social protection is a fundamental right that should be accessible to all including people with HIV and key populations. In practice, attention should be given to information providing and addressing barriers such as the registration processes, lack of required documentations, punitive laws that lock out key populations from accessing services and social protection, stigma and discrimination.

Thank you for your important contributions!

Roy Small  opens his comment with a nice pharse saying that a just and sustainable COVID-19 response and recovery should lift up those who are vulnerable and marginalized in greater measure than the pandemic has set them back. Strengthening and integrating the social safety nets built on the fly during the pandemic, and sustaining these on the path back to the SDGs, is a major opportunity to support critical HIV-related needs.

Your thoughts and links of examples of innovative ways to expand domestic resources are much appreciated. These include debt standstill, the importance of identifying and efficiently financing high impact and integrated solutions, sugar, alcohol and tobacco taxes. Thank you for addressing the finance issue.

Dear contributors,

Thank you all for your excellent contributions of the past week.

We received comments on a wide range of topics. In summary, on barriers to access social protection programmes, were mentioned: stigma and discrimination, criminalization of behaviour of key populations, complicated registration processes with documentation that is sometimes lacking, and the fear of disclosure.

On best practices, both the universal health coverage as a system to improve country ownership as well as a cash transfer programme for orphans and vulnerable children in Kenya were mentioned. More recent best practice ideas come from the social networks set up around COVID-19 and how these can be expanded and integrated. The experience around COVID-19 was also mentioned as an accelerator for the HIV response. However it is also mentioned that people living with HIV are not prioritized because HIV is not recognized as a chronic disease and social protection programmes in general should be more structural.  

Other important elements that were mentioned are a joint coordinated response, documentation of good practices, meaningful participation of the populations involved, political and financial commitment, data collection on socio-economic impact on key populations, improving access by adding HIV sensitive considerations to registration systems and the specific challenges in the informal sector where a lot of people living with HIV and key populations depend on for their livelihoods.

I think the comment to see social protection as an investment in building resilience, not as expenditure alone, combined with the examples of expanding domestic resources by debt standstill, the importance of identifying and efficiently financing high impact and integrated solutions, sugar, alcohol and tobacco taxes, are key to promote social protection programmes nationally.

In case you haven't registered yet for the Global Dialogue on Social Protection for People Living with HIV and Key Populations on 18-19 May (a 2-hour session each day), please do so here and feel free to widely share with others!

I hand over to Boyan Konstantinov from the UNDP for the final days of moderation on this very interesting platform.

All the best and I hope to 'see' you all on 18 and 19 May.

Diddie

1. What are the needs and challenges of people with HIV and key populations (in general and for specific populations) and social protection, including in the context of COVID-19, in your country and region?

Key populations share the experience of criminalisation, stigma, discrimination, violence and social exclusion in most settings. The net effect is poorer access to health and social services, compounded by fear of repercussions if self identifying as a member of a KP group and other legal barriers e.g. exclusion due to ongoing illicit drug use or sex work, lack of legal recognition of transgender and other gender non-confirming groups. Yet, key populations may be at increased need of social protection given the intersection of poverty, disability, unemployment and communicable diseases for these groups. COVID-19 has highlighted these inequities. 

2. Identify and discuss good practices and lessons learned, as well as opportunities for future action in social protection in national HIV responses and in making social protection schemes HIV and key populations – sensitive.  Provide examples from your country and region.

UHC provides a good framework for prioritising key populations in the move towards universal health coverage. The concept of progressive universalism, where countries create policies which aim to first reach those most vulnerable and progressively move to reach the greater population are useful in this context. The commitment to "leave no one behind" is also particularly relevant. Countries can implement pragmatic policies to provide health and social services to those that are criminalised while working towards a longer term goal of decriminalisation of drug use, homosexuality, sex work and transgender (as recommended by WHO and other UN agencies)

2. What is the main message on social protection for people with HIV and key populations that should be included in the next Political Declaration on HIV and AIDS?

Key populations and those living with HIV should be priority populations for reaching universal health and social protection given potential vulnerabilities and needs. This means reaching first those that are most vulnerable and actioning this through tangible commitments that can be measured and reported on. Communities should be involved in monitoring these commitments and given respectful space to discuss gaps and issues. 

Universal coverage can be acheived in part through implementation of a range of enabling interventions, as recommended by WHO in the KP guidelines, with adequate funding and recognition of the rights of all people. 

UNAIDS, co-sponsors and partners have developed guidance materials and conducted HIV and Social Protection Assessments in more than 16 countries from Asia Pacific, Eastern and Southern Africa, West and Central Africa and Latin America and the Caribbean, which speak to many of the issues in the discussion.

We have generated evidence of the barriers people living with HIV and key populations face in accessing social protection benefits. The barriers include:

• Complicated procedures.
• Lack of identity cards.
• Stigma and discrimination.
• Limited social protection programmes
• Lack of information on available programmes.
• Transport costs 

Here is the Social Protection a Fast-Track Commitment for detailed guidance on Fast-tracking access to social protection and the HIV and Social Protection Assessment Tool, for generating evidence on who is left behind by social protection programmes. See the most recent HIV and Social Protection Assessment report from Zimbabwe. 

I encourage countries that have conducted the assessment to share their thoughts and reports. 

Best wishes, David Chipanta

Senior Advisor Social Protection, UNAIDS

HIV and Social Protection Assessment in Zimbabwe.pdf3.89 MB

Pregunta 1

RESPUESTA CONSOLIDADA DE ALGUNAS ORGANIZACIONES

1. En la Republica Dominicana entre los retos que tienen que enfrentar las personas viviendo con VHI está la de un diagnóstico temprano y vinculación al tratamiento sin un protocolo de adherencia y educación  a los nuevos diagnosticados y sin una consejería adecuada, las directrices refieren que un paciente recién diagnosticado con VIH entre a tratamiento de inmediato, sin tomar en consideración que un paciente recién diagnosticado debe tener un proceso para aceptar su nueva condición y ser preparado para recibir un tratamiento que será de por vida y al no seguir este proceso sucede una pérdida o desperdicio de medicamentos y que el paciente termine en abandono.
2. Otra situación es la referente al estigma y discriminación asociadas al VIH, dentro de los servicios lo prestadores de servicios al no estar capacitados y sensibilizados frente a las personas con VIH, muchas veces incurren en maltratos.
3. Al no seguirse El protocolo no se sigue según lo dispuesto por los organismos oficiales y cada unidad se rige según crea la persona encargada.
4. Mecanismo inefectivo para enfrentar los posibles desabastecimientos de antirretrovirales.
5. La lenta implementación de nuevas formas de prevención.

Pregunta 2

1. Implementar políticas y programas para fortalecer la respuesta al VIH tales como un monitoreo continuo, trabajos comunitarios, programas de adherencia continua, educación continua para fortalecer las capacidades de las personas que viven con VIH y de los prestadores de salud.
2. Invertir en el desarrollo continuo y de buena calidad en los servicios prestados dentro de las unidades de atención integral.
3. Establecer acuerdos multisectoriales y comprometerse con los procesos de transformación personal y organizativa para lograr directrices efectivas para lograr los objetivos trazados para el 2030.
4. Aprovechar y contribuir a la base de pruebas para la prevención de nuevas infecciones y para frenar el estigma y discriminación en cualquier forma.
5. Planificar debidamente y asignar los recursos suficientes para implementar programas sociales que protejan a las poblaciones vulnerables ya que los programas de ayudas sociales existentes no contemplan a estas poblaciones y no son priorizados.

Pregunta 3

1. El mensaje principal seria * Detener el estigma y la discriminación en cualquier forma*, desde el leguaje para referirse al VIH hasta el trato a las personas con VIH en los centros de salud y en sus lugares de trabajo y en todo el ámbito social.
2. Crear un monitoreo continuo para que los programas de protección social lleguen a las personas con VIH y poblaciones y que este monitoreo sea encabezado por estas mismas poblaciones.
3. que existan recursos para la prevención y así evitar infecciones por el VIH y otras infecciones de transmisión sexual.
4. Debería haber sanciones rígidas para enfrentar las violaciones a los acuerdos internacionales contraídos para los países que no han cumplido, así como reforzar las leyes locales para castigar a las instituciones que provoquen el estigma y discriminación de cualquier forma posible.

Virginia Macdonald,, thank you for putting the emphasis on universal health coverage which is indeed of critical importance for meaningful social protection and an Agenda 2030 commitment, David Chipanta, thanls for sharing these most practical concerns and also the helpful tools from Zimbabwe, very specific constraints and good practices. Pedro Jose Reyes, a sobering reflections on the difference between laws and policies on paper and lived realities of communities - and on the fact that sometimes implementation of policies is much slower than it should be.

Dear Participants, we have a little more time left for this discussion, so I encourage everyone who has any comments to make, or materials to share to do so today, before we close the session. At the end, we will provide a summary of these comments and the discussion in general. Everyone, have a great week!

Dear Diddie and Boyan, thanks for an invitation to join this dialogue. Already rich input has been provided - I am not sure I have much to add. From our perspective, COVID-19 has magnified existing inequities - in many settings key and vulnerable populations face criminalization, stigma, discrimination, violence, homelessness, and food insecurity which can increase vulnerability to COVID-19. To facilitate KVPs to continue accessing prevention services and to support those on treatment for better treatment outcome, it is essential to provide social protection. Some activities below are what we encourage to be included as part of funding application to the Global Fund as part of C19RM - specific response mechanism to: a) adapt service delivery to ensure continuity of services; b) strengthen national covid-19 response; and c) strengthen community and health systems. without adequate support to the below, it is very likely that KVPs will continue to be marginalised and felt the most impact of the epidemic on their health, well-being and their rights.

•Nutritional support (and other livelihood packages) for KVPs and some people living with/affected by the diseases

•Scale-up existing rapid response mechanisms, including existing temporary shelters with comprehensive services for victims of GBV and human rights violations

•Prioritize continuity of services supporting people with disabilities, and scale up if possible, including phone /online support.

Directly respond to the increase in poor mental health outcomes that arise from COVID-19 fears and social isolation:

•Build on existing infrastructure for KVPs to support one another, such as peer support (support groups, online/phone-based support mechanisms)

•Support social mobilization and education of communities including through organizing online or phone-based activities that are informative and allow for social connection

•Increase mental health support available to beneficiaries through online and virtual platforms

As the saying goes, "better late than never" and i hope i am not being repetitive. This has been a very interactive dialogue and i enjoyed reading contributions from colleagues. If i am repeating, then it means we cant over emphasize the need to support social protection for people living with HIV and other KPs. My focus though is on NGO Social contracting and the Social Return on Investing in services delivered by NGOs to reach the furthest left behind.

1. What are the needs and challenges of people with HIV and key populations (in general and for specific populations) and social protection, including in the context of COVID-19, in your country and region?

Needs of PLHIV and KPs in EECA region:

• Advocacy in support of KP programming in countries especially where KPs are being recriminalized, or where crackdowns are resulting in reduced access to KP
• Inadequate global partners mobilization in a quick and efficient way to provide assistance when necessary.
• Limited documentation of evidence of positive outcomes from police engagement in supporting HIV prevention needs.
• Regional assistance to assist countries to strengthen mechanisms for state funding of services delivered by CSOs (NGO Social contracting).
• Assured and effective linkage to treatment, care and support for newly diagnosed KP living with HIV, in order to maximize the health benefits of HIV testing.
• Inadequate targeting of testing to reach undiagnosed KP in sufficient numbers and offering differentiation of ART service models to better meet the needs of KP.
• Inadequate outreach and support services especially during pandemic such as COVID-19  to ensure that there are sufficient resources for linkage to treatment for newly diagnosed PLHIV and case-management  
• Inadequate focus on Test and Treat means that broad HIV information and prevention programs are wound back in many countries.
• KP NGOs need resources to support health-seeking behaviors, particularly among young KP, to address stigma and discrimination and to develop and disseminate messages and information about living positively with HIV.

Challenges:

• Political, legal and technical barriers in many national HIV programmes are delaying the use of new, innovative approaches and tools, such as self-testing and pre-exposure prophylaxis (PrEP).
• The region is also not on track to reach the Fast Track 90-90-90 targets
• Although knowledge of HIV status is not bad overall, ART coverage and viral suppression among all PLHIV in the EECA region are poor. Moreover, adequate availability of community-based testing and counseling or lay provider testing is lacking in most countries in the region, as is ART provision in community settings

2. What is the funding situation of social protection schemes for people living with HIV and key populations – how much are they covered from international donors, domestic government sources, private sources? What is paid out of pocket?

Funding situation for social protection

Barriers to HIV prevention in EECA include economic, social, legal, and other barriers. Lack of funding for HIV is a major economic barrier for scaling up HIV prevention programs. When the funds are available, they are put toward programs for the general population instead of key populations. In addition, prevention programs are under threat in the region because of reduced international support and often inadequate domestic funding (UNAIDS 2016b).

3. Identify and discuss good practices and lessons learned, as well as opportunities for future action in social protection in national HIV responses and in making social protection schemes HIV and key populations – sensitive.  Provide examples from your country and region.

Good practices and opportunities for the future:

UNDP Regional hub has facilitated learning and implementation of NGO social contracting and in this regard between 2016-2018 supported development of NGO social contracting fact sheets. Working with national stakeholders, the aim is to let NGOs be explicitly recognized as partners and service providers in HIV, KP public health legislation and policies. The fact sheets provide overviews of the HIV epidemiology and responses, the role of NGO social contracting in the national HIV response, and recommendations to national stakeholders on increasing the efficiency and effectiveness of the existing social contracting mechanisms. Also developed a How to conduct social contracting methodology.

4. What is the main message on social protection for people with HIV and key populations that should be included in the next Political Declaration on HIV and AIDS?

Key messages:

• There is Social Return on Investing (SROI) in NGO service delivery to reach the furthest left behind.
• The SROI analysis should and can be used in the management of programmes and for decision making.
• SROI is useful for advocacy and to lobbying activities that can and should be executed by NGOs to emphasize the benefits of social contracting.
• SROI can be used to show that some activities, like harm reduction can be effectively and efficiently delivered by NGOs in a non-clinical setting.
• SROI analysis can also be used for sustainability and medium-term effects of some activities implemented through social contracting.
• Marginalization of key populations, the high returns on investment cannot be achieved without activities implemented through social contracting.

Dear Organizers, 

Thanks for initiating this important discussion. Following the COVID-19 pandemic in 2020 UNDP partnered with the Africa Key Population Experts Group to undertake a rapid scan of its impact and on mobilizing key population activists and leaders in the continent for protection of key population communities during COVID-19. Some of the lessons drawn from this rapid scan might be useful for this conversation.

COVID-19 containment measures, in particular the widespread use of often protracted lockdowns at the onset of the pandemic, has had a huge impact on all communities in Africa. However, these measures disproportionately affected the urban poor and marginalized communities especially those who are largely dependent on incomes derived from the informal economy.

The rapid scan has shown that some key population communities particularly sex workers faced huge challenge in sustaining their livelihoods. The loss of income is directly associated to food insecurity for sex workers and their dependents. In addition, it also led to loss of housing as sex workers struggled to pay rent leading to displacement and migration. This further leaves them even more vulnerable to the consequences of the laws where the homeless are being detained in a situation similar to “forced quarantine”. The problem was further compounded by already existing vulnerabilities such as exclusion from government driven social protection schemes and relief efforts put in place to address the effects the COVID-19 pandemic.

As the pandemic-related restrictions on movement and economic activity continue for longer periods of time, some community members start taking increased risks such as meeting clients in insecure spaces leaving them more vulnerable and prone to violence and rape. The restrictions imposed to control the pandemic resulted in further deterioration of an already punitive legal regime in many counties leaving key population communities more vulnerable to excessive action and violence by law enforcement. 

The rapid assessment indicated that key population communities, activists and leaders have quickly recognized this challenge and started to put in place measures that limit their vulnerability and increase their integration in national responses to the pandemic. For instance in Kenya, the Kenyan Sex Worker Alliance (KESWA) started to raise funds using a mobile based app “MCHANGA” – (Swahili for contribute) to mobilize resources to purchase nonperishable foods and household items such as soap, sanitizers and bleach which were distributed to their member organizations across the country.  KESWA also started a toll-free number to respond to the needs of sex workers across the country.  Though this service, KESWA deployed trained counsellors provided advisory services both to individual members of the community and key population groups on ways of accessing COVID-19 related services, counselling for victims of violence and access to social safety net programmes.  

The experience from KESWA and other organizations in Africa showed that the first line of response for key population communities in times of crises such as COVID-19 are often their own orgaizations and self-help groups. It is, therefore important that social protection strategies put in place at national and sub-national levels make specific effort to integrate these community initiatives in their design and implementation.

@Ed N. thanks so much for providing this important nexus between social protection and funding applications with the Global Fund. Excellent to see that services expand to cover nutrition, shelter, mental health support and also address intersectionalities such as disability. Rosemary Kumwenda  the situation of KPs is particularly challenging in the EECA region, which is also the region with the fastest growing HIV infections. You pack a lot in this message in terms of legal and structural barriers but also under-delivery on the pledge to increase domestic funding. CSO social contracting is an excellent opportunity to wisely invest domestic resources and why not expand service to social protection? Communities in EECA has been doing this, as evidenced by earlier input to our discussion. Social return on investment is a topic that we plan to explore together with donors and academics on 19 May, during the special session on funding at the Global Dialogue. Mesfin Getahun , excellent points on the impact of COVID-19 and very good to learn about this practical tool Mchanga, developed in Kenya by the Kenyan Sex Workers Alliance. It would be great to hear more about it  during the Global dialogue, particularly on 18 May during the session on good practices.

Dear Colleagues, thank you, thank you, thank you! Our SparkBlue consultation is now coming to an end. You have been very generous with your time and expertise and have provided helpful insights from various regions and various perspectives. Your input comes to show that social protection for people living with HIV and key populations is instrumental for delivering on the Agenda 2030 pledge to ned AIDS as a public health threat by 2030 while leaving no one behind. Your input will feed into the Global Dialogue o 18-19 May, which will result in developing a checklist with concrete recommendations and proposed actions for various stakeholders to inform future policy and programme work.

We look forward to seeing you there. In case you haven't registered, please do so through the following link:

Once again many thanks for your participation and contributions.