Determining Barriers to Creating an Enabling Environment in Cambodia: Results from a Baseline Study with Key Populations and Police

"...our results indicate that current punitive laws and policies and their implementation have created an environment in which key populations in Cambodia are burdened by fear of and actual harassment and arrest."

To understand how enforcement of Cambodian laws creates barriers to HIV service implementation for key populations, including men who have sex with men (MSM), people who inject drugs (PWID), and sex workers (SWs), FHI 360 supported the Ministry of Interior to implement the Police Community Partnership Initiative (PCPI) in Cambodia's capital Phnom Penh with funding from the Australian Department of Foreign Affairs and Trade. To guide this, FHI 360 conducted a baseline study examining (i) police and key populations' attitudes and practices towards one another, including fear and occurrence of arrest; and (ii) HIV prevention actions and actions toward police among key populations.

As outlined in the introductory section of this report, widespread consensus exists among government, United Nations (UN) agencies, non-governmental organisations (NGOs), and health and social service providers that "in order to halt national HIV epidemics an enabling environment must be created to support HIV prevention and treatment while also ensuring law enforcement and public safety". The authors clarify that "[n]egative impacts of punitive drug policies and related human rights abuses are particularly experienced by people who use drugs (PWUD) and sex worker populations." They explain: "Facilitating a harm reduction approach in which police link key populations to needed services rather than detain or arrest them, PCPI entails regular coordination meetings and sensitization workshops at community level, capacity building, facilitated dialogue and problem solving among participating stakeholders."

In order to gather data to serve as a measure for assessing the effectiveness of the PCPI approach, between December 2012 and January 2013, the authors conducted cross-sectional survey (structured interviews) of 199 police officers, 199 PWUDs including PWID, 199 MSM, 200 transgender women (TGW), and 200 female entertainment workers (FEW) in 5 Phnom Penh districts. Findings indicated that 11% of respondents had experienced arrest in the previous 6 months, 29% experienced verbal intimidation, and 25% experienced a body search. PWID reported higher incidence of these events than other key population groups. The majority of key population participants (60.5%), particularly PWUD (75.4%), felt that police were unkind. Key populations feared arrest for carrying needles and syringes (67%) and condoms (23%), and 19% felt afraid to access health services. Close to 75% of police reported body searching and 58% arresting key populations in the past 6 months for using drugs (64%), selling or distributing drugs (36%), or being violent (13%). All police voiced support for HIV prevention; the majority (94%) believed arrest was an appropriate solution to reduce HIV and drug use and reported selling sex (88%) and carrying needles and syringes (55%) as valid reasons for arrest.

Reflecting on these findings, the authors argue that, "[t]o create an enabling environment and ensure police are allies in the Cambodian HIV response, interventions should tackle underlying negative attitudes among police towards key populations and vice versa." They suggest that specific research-informed interventions for each key population group are necessary due, for example, due to their finding that "[r]easons for fearing police differed among key populations, suggesting that efforts to change attitudes need to be tailored to each group". PWUD not only feared arrest for carrying needles or syringes (66%), but also most commonly reported relocating because of fear of police, making this group hard to reach and impeding HIV outreach activities. The study also found fear of arrest for carrying condoms, which was reported most often by FEW. Yet, research has shown that, when governments support condom use, for instance, as in the Dominican Republic, where the government sanctioned condom availability in establishments and monitored establishments to ensure supplies, there is a positive influence on consistent condom use among FEW. "The fear identified in Cambodia likely reflects the negative influence of the 2008 legislation prohibiting sex work on prevention efforts, access to outreach, peer support, and condom use among this population."

Pointing to the contradiction between attitudes and practice on the part of police - they support HIV prevention and harm reduction services in their community yet arrest and detain key population as a strategy - "suggests a need to clarify how to operationalize and harmonize existing laws and policies and to foster understanding of the mutual benefits of harm reduction to HIV and law enforcement efforts....It further suggests that future efforts aiming to align law enforcement with HIV services and wider public health goals, such as PCPI, must address the underlying negative attitudes held by key populations and police. Such efforts should be tailored to each key population group and evaluated for effectiveness."

The authors conclude: "A paradigm shift from punitive laws and policies towards harm reduction and rights-based principles, as well as effective multi-sectoral collaboration are all imperative for reducing HIV in Cambodia and other countries with key population driven HIV epidemics."