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Published in final edited form as: Drug Alcohol Depend. 2013 Jul 26;132 Suppl 1:10.1016/j.drugalcdep.2013.06.027. doi: 10.1016/j.drugalcdep.2013.06.027

Police Education as a Component of National HIV Response: Lessons from Kyrgyzstan

Leo Beletsky (1),(4), Rachel Thomas (2), Natalya Shumskaya (3), Irina Artamonova (4), Marina Smelyanskaya (5)
PMCID: PMC3825798  NIHMSID: NIHMS510497  PMID: 23896307

Abstract

Background

Recognition of the police department’s role in shaping HIV spread and prevention has generated interest in educational interventions targeting law enforcement. With input from civil society, trainings covering HIV prevention science, policy, and occupational safety were developed and delivered to cadets and active-duty police across Kyrgyzstan.

Methods

We administered a multi-site cross-sectional survey of Kyrgyz police to assess whether undergoing HIV trainings was associated with improved legal and public health knowledge, positive attitudes towards public health programs and policies, occupational safety awareness, and intended practices targeting vulnerable groups.

Results

In 313-officer sample, 38% reported undergoing the training. In multivariate analysis, training was associated with being significantly more likely to support referring individuals to harm reduction organizations (aOR 2.21; 95%CI 1.33–3.68), expressing no intent to extrajudicially confiscate syringes (aOR 1.92; 95%CI 1.09–3.39), and better understanding sex worker detention procedure (aOR 2.23; 95%CI 1.19–4.46), although trainee knowledge of policy on routine identification checks for sex workers was significantly lower (aOR 3.0; 95%CI 1.78–5.05). Training was also associated with improved occupational safety knowledge (aOR 3.85; 95%CI 1.66–8.95).

Conclusion

Kyrgyzstan’s experience suggest that police trainings have the potential to improve the integration of policing and public health efforts targeting at-risk groups. Regardless of the legal environment, such structural approaches should be considered elsewhere in Central Asia and beyond. As these initiatives gain acceptance, further research is needed to inform their design and tailoring.

Keywords: Central Asia, Injection drug use, structural interventions, policing, police training, HIV, HIV prevention

1. INTRODUCTION

Situated along the ancient Silk Road linking Europe to Asia, Kyrgyzstan has become an increasingly important transportation corridor for Afghani opium and itinerant labor. This has fuelled epidemics of bloodborne and sexually-transmitted infections (STIs) among people who inject drugs (PWID), sex workers, and migrants. Prevalence of HIV reaches 50 times and 5 times the background rate among PWID and sex workers, respectively; three-quarters of Kyrgyz HIV cases can be directly or indirectly attributed to injection drug use (World Health Organization, 2009).

A legal environment that emphasizes public health over punishment and stigmatization is critical to an effective HIV response (Cohen and Csete, 2006; UNDP, 2012). Relative to its Central Asian neighbors, Kyrgyzstan has fostered such an environment, including decriminalization of small-scale drug possession and rejection of criminal penalties for sex work. Police practices frequently deviate from formal laws because of poor legal and public health knowledge, negative attitudes towards harm reduction, occupational safety concerns, and perverse incentives (Beletsky et al., 2005, 2012b; Burris et al., 2004; Rhodes et al., 2006; Beletsky et al. In press; Beyer et al., 2002).

The Kyrgyz HIV response includes innovative structural efforts to harmonize police practice with public health. Starting in 2005, AIDS Foundation East West (AFEW) and its partners conducted police trainings. This has included persuading the Republican Police Academy to integrate a 46-hour “Special Course” on harm reduction delivered by civil society and police professionals to future top brass (AIDS Foundation East-West, 2013). At the police high school, ad-hoc shorter modules were delivered to junior officers-in-training. Among active-duty personnel, over 500 police throughout Kyrgyzstan completed 17 educational programs. These efforts built on Instruction (“Prikaz”) 417 — an internal policy directing police to facilitate HIV prevention initiatives (Beletsky et al., 2012b).

Though varied in setting and audience, the trainings shared content components: 1. core public health information on HIV and STIs, 2. law and institutional policy related to sex work and drug use, 3. occupational safety precautions, and 4. contact information for local harm reduction programs. However, none were formally evaluated, which parallels the lack of evaluation of police education by US organizations (Beletsky et al., 2011b). At a time when the need to engage law enforcement in effective HIV response has become increasingly recognized (Law Enforcement and HIV Network, 2013), we are not aware of any study evaluating police trainings outside of US context (Beletsky et al., 2011a; Davis and Beletsky, 2009; Silverman et al., 2012).

In 2010, AFEW mounted a national survey to understand police knowledge, attitudes, and practices related to harm reduction programs across Kyrgyzstan (Beletsky et al., 2012b). This analysis assesses whether having undergone an HIV-prevention training was associated with a set of outcomes conducive to HIV prevention.

2. METHODS

2.1 Study Design

Study methods were detailed elsewhere (Beletsky et al., 2012b). Briefly, a self-administered paper survey of police serving at least one year was distributed in eight diverse, purposefully-selected precincts across Kyrgyzstan. Data were centrally processed by AFEW. The Institutional Review Board at the University of California, San Diego approved the study.

2.2. Study Instrument

Based on Diffusion of Information Theory (Rogers, 1995), items from studies of police attitudes and training (Beletsky et al., 2011a, 2005) the instrument assessed sociodemographics, core knowledge of HIV transmission and prevention (UNAIDS, 2009), attitudes toward public health prevention efforts targeting PWID and sex workers, knowledge and experience of occupational risks and precautions related to bloodborne infections, past and intended practices, and criminal procedure. Knowledge and action items used true/false or multiple-choice options, while attitudinal questions used 4-item Likert scales assessing respondent agreement (strongly agree-strongly disagree).

2.3 Analytical Methods

This analysis focuses on associations between the report of having undergone an HIV prevention training with attitudinal, knowledge, and action variables related to public health policy and practice. Based on training content and previous research (Beletsky et al., 2011a; Davis and Beletsky, 2009; Silverman et al., 2012), we hypothesized that undergoing such training would increase knowledge about HIV risk and prevention programming; legal knowledge, including detention policies; attitudes towards harm reduction programs; and prevalence of actual and intended police practices reflecting public health goals. We assessed sociodemographics (gender, ethnicity, age, years of police service, rank), geographical setting (serving in a municipality vs. town or village), having knowledge of Prikaz 417, or having had recent contact with harm reduction NGOs as potential confounders.

We used SAS software, version 9 (SAS, Cary, North Carolina) to analyze the data. Likert items were dichotomized. The Fisher exact test was used for binary variables, while chi-square test for categorical variables was utilized to stratify samples based on our exposure variable. For continuous variables, Wilcoxon rank-sum tests were used. Bivariate analysis was conducted using simple logistic regression (see Table 1); independent variables significant at the p<0.05 level were included in a multiple logistic regression model (see Table 2).

Table 1.

Descriptive statistics and unadjusted odds ratios for factors associated with completing HIV training, Kyrgyz police (n=313)

Variable Category of Interest Completed Training n=119 Did not Complete Training n=194 Total N=313 Unadjusted Odds Ratio 95% Confidence Interval
Sociodemographics
 Age > 30 y.o. 55 (46.6%) 90 (46.6%) 145 (46.6%) 1.00 (0.63–1.58)
 Sex Male 109 (91.6%) 180 (93.3%) 289 (92.6%) 0.79 (0.33–1.86)
 Rank Cadet/private 27 (22.7%) 37 19.1%) 64 (20.4%) Ref
Officer 92 (77.3%) 157 (80.9%) 249 (79.6%) 0.80 (0.46–1.40)
 Geographical setting where serving Urban 96 (81.4%) 101 (52.1%) 197 (63.1%) Ref
Semi rurl/rurl 22 (18.6%) 93 (47.9%) 115 (36.9%) 0.25 (0.14–0.43)
 Years in policing > 10 yrs. 63 (54.3%) 108 (56.0%) 171 (55.3%) 0.94 (0.59–1.49)
 Graduate of the National Police Academy Yes 44 (37.3%) 54 (28.1%) 98 (31.6%) 1.52 (0.93–2.48)
HIV knowledge, attitudes and experience
 UNGASS HIV Transmission Knowledge Scale Median (IQR) 8 (7–9) 7 (6–8) 7 (6–8) 1.39 (1.16–1.65)
 Attitude on syringe distribution as a public health measure Positive 78 (65.5%) 120 (62.5%) 198 (63.7%) 1.14 (0.71–1.84)
 Attitude on condom distribution as a public health measure Positive 85 (72.0%) 139 (72.4%) 224 (72.3%) 0.98 (0.59–1.64)
 Attitude on raids against SWs as a public health measure Negative 64 (53.8%) 124 (64.6%) 188 (60.5%) 0.64 (0.40–1.02)
 Attitude on police educating at-risk groups about HIV risk reduction Positive 67 (56.3%) 61 (31.8%) 128 (41.2%) 2.77 (1.72–4.44)
 Familiar with organizations serving at-risk groups in locale Attitude on police referring at-risk groups to HIV prevention service organizations Positive Yes 28 78 (23.5%) (68.4%) 34 57 (29.5%) (17.6%) 135 62 (19.9%) (44.0%) 1.44 5.17 (0.82–2.53) (3.13–8.54)
 Met with staff from organizations serving at-risk groups (last 6 mo.) Yes 45 (39.5%) 14 (7.2%) 59 (19.2%) 8.38 (4.33–16.23)
Occupational safety knowledge, attitudes and experience
 Has experienced occupational NSI (lifetime) Yes 3 (2.5%) 20 (10.4%) 23 (7.4%) 0.22 (0.07–0.77)
 Concern about contracting disease from occupational NSI Yes 93 (80.9%) 157 (81.8%) 250 (81.4%) 1.06 (0.59–1.92)
 Syringe access for PWID increases risk of occupational NSI Disagree 86 (72.3%) 116 (60.4%) 202 (65.0%) 1.71 (1.04–2.80)
 Knowledge workplace safety procedures, blood exposure Correct 19 (16.0%) 12 (6.2%) 31 (9.9%) 2.88 (1.34–6.18)
Legal and policy knowledge
 Knowledge of law on possession of injecting equipment Correct 61 (52.1%) 107 (55.4%) 168 (54.2%) 0.88 (0.55–1.39)
 Knowledge of Instruction 417 on HIV Prevention Correct 62 (52.1%) 70 (36.5%) 132 (42.4%) 1.90 (1.19–3.02)
 Policy should emphasize support, prevention for at-risk groups Agree 108 (90.8%) 149 (77.6%) 257 (82.6%) 2.83 (1.40–5.75)
 Policy is to check SW identification when encounter on street Disagree 60 (50.4%) 143 (74.1%) 203 (65.1%) 0.36 (0.22–0.58)
 Policy is to detain SW when encounter on street Disagree 103 (86.6%) 142 (73.6%) 245 (78.5%) 1.87 (1.11–3.17)
Would confiscate syringes from PWUDs w/o formal charges/arrest Yes 41 (34.7%) 39 (20.4%) 80 (25.9%) 2.08 (1.24–3.48)
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Table 2.

Multivariate model

Variable Adjusted Odds Ratios 95% Wald Confidence Interval
Police should refer PWID/SW to HIV prevention services 2.21 (1.33–3.68)
Would not confiscate syringes from PWID w/o formal charges/arrest 1.92 (1.09–3.39)
Police should not detain SW when encounter on street 2.23 (1.19–4.46)
Police should check SW identification when encounter on street 3.0 (1.78–5.05)
Knowledge workplace safety procedures, blood exposure 3.85 (1.66–8.95)
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3. RESULTS

As previously reported (Beletsky et al., 2012b), our study achieved an overall response rate of 64% with 319 completed surveys. This analysis focuses on 313 individuals who responded to the training item. Table 1 illustrates that this sample comprised a diverse group of Kyrgyz police, dominated by relatively mature, experienced, and urban male officers.

Based on standard indicators, respondents exhibited high levels of knowledge about HIV transmission and prevention (median of 7 on a 9-item scale; UNAIDS, 2009). Respondents held positive attitudes toward syringe (63.7%) and condom (72.3%) access. However, support for propositions that police should provide public health prevention information to high-risk groups was substantially lower (41.2%). Respondents were somewhat equivocal about whether sex worker raids promote public health (60.5%), and exhibited only moderate familiarity with local harm reduction organizations (44%) and contact (19.2%, last 6 months). Just over 38% reported undergoing an HIV training.

Although a small minority (7.4%) reported lifetime needle stick injuries (NSI), concern about contracting disease through NSI was widespread (81.4%). Thirty-five percent of respondents acknowledged alarm that syringe access may increase police occupational risk. Less than 10% reported accurate knowledge of procedures in the case of exposure to blood in the line of duty.

Findings indicate inconsistent levels of legal and policy knowledge: Most respondents (82.6%) agreed that government policies should emphasize public health and social support for marginalized populations, but many incorrectly characterized Kyrgyz law on syringe possession (46%) and sex work (22%). Just over 42% reported knowledge of Prikaz 417. Importantly, more than one-in-four indicated intent to confiscate injection equipment even absent a legal reason to do so.

In bivariate analyses (Table 1), training was significantly associated with serving in an urban setting, better HIV transmission knowledge, and support for the role of police in educating high-risk groups. Trainees were less likely to report occupational NSI and to back the assertion that syringe access increases occupational risk. They also exhibited better legal and policy knowledge; trainings were associated with lower levels of correct knowledge only on the issue of routine sex worker identification. Those who had undergone training were also more likely to report familiarity and interactions with public health organizations.

Table 2 lists the variables that remained significant in the final multivariate model. Our analyses suggest that trainees were more likely (adjusted odds ratio [aOR] 2.21; 95% confidence interval [CI] 1.33–3.68) to agree that members of high risk groups should be referred to harm reduction organizations and were more likely to indicate no intent to confiscate injection equipment without legal cause (aOR 1.92; 95%CI 1.09–3.39)). They also demonstrated significantly higher odds of understanding sex work detention procedure (aOR 2.23; 95%CI (1.19–4.46)), but trainee knowledge of policy on requesting sex worker identification was more likely to be incorrect (aOR 3.0; 95%CI (1.78–5.05)). Training was also independently associated with understanding procedures after occupational blood exposure (aOR 3.85; 95%CI (1.66–8.95)).

4. DISCUSSION

Our analyses support the hypotheses that police training facilitates better integration of policing and public health efforts targeting high-risk groups. Evidence that trainees were significantly less likely to intend to confiscate injection equipment charts a distinct potential of police trainings to mitigate the damage caused by extrajudicial and intensive policing (Aitken et al., 2002; Beletsky et al., 2012a; Cooper et al., 2005; Davis et al., 2005; Human Rights Watch, 2003). In particular, Extrajudicial syringe confiscation has been reported by both police and drug users in a range of studies across the world (Beletsky et al., 2005; Booth et al., 2009; Fairbairn et al., 2009; Hammett et al., 2005; Pollini et al., 2008; Rhodes et al., 2006; Strathdee et al., 2010; Werb et al., 2008; Beletsky et al, In press). This practice is now widely understood to cause public health harm because of its established empirical links to HIV risk behaviors like receptive syringe sharing, as well as to actual HIV status (Beletsky et al., 2013; Strathdee et al., 2011).

Trainees were significantly more likely to agree that police should refer at-risk individuals to service programs. Given routine police contact with PWID and sex workers, referrals represent one of the most promising areas of actionable police-public health collaboration (Beletsky et al., 2011c). Our data suggest, however, that such referrals remain rare even among police who are informed about local harm reduction organizations. To incentivize referrals and other cooperation, AFEW recently developed new police guidelines and established an award for Kyrgyz law enforcement officers who excel in their contribution to HIV prevention, including service referrals (AIDS Foundation East-West, 2013). After evaluation, promising incentive mechanisms must be integrated into any legal, policy and managerial interventions to reform police practices.

Our finding a significant relationship between the training and improved occupational safety knowledge is encouraging. In addition to addressing genuine workplace safety gaps and job-related stress among police, the bundling of occupational safety and community health content in the realm of HIV prevention can help make the training curricula more engaging and acceptable to police audiences (Davis and Beletsky, 2009). Including occupational safety tips and other safety topics in training curricula can incentivize both training participation and uptake.

These trainings produced mixed results in the realm of street-based sex work regulation: respondents were more likely to understand that sex workers should not be detained, but were also less likely to correctly characterize the policy on routine identification checks. Routine identification checks may be a framework for gathering bribes from sex markets, which would explain general police support for the practice; this does not explain, however, why trainees appeared to support it at higher levels.

4.1 Limitations

The study’s methodological limitations are addressed elsewhere (Beletsky et al., 2012b). Findings may not be generalizable to all Kyrgyz police, given the non-random sampling. Also, AFEW and its partners conducted a number of training initiatives that contained common curricular elements but varied widely in duration, instructors, and setting. Some contamination may have occurred as training content was disseminated through networks, shifting background levels of police knowledge and introducing the possibility of systematic social desirability bias in attitudinal and intended practice questions.

In Kyrgyzstan as well as elsewhere in Central Asia and beyond, a number of factors perpetuate misalignment between police and public health efforts, making it unlikely that training interventions can sufficiently change police practice. Dysfunctional governance, poor management, low pay, and personnel turnover are compounded by cultural and religious attitudes towards marginalized groups, draconian laws, weak judiciaries, and pervasive corruption. Partnerships with broader human rights and criminal justice reform efforts are critical to the success of structural interventions aiming to shift police practices towards public health goals.

4.2 Conclusion

Increasing recognition of the importance of integration of policing and public health has generated active interest in ways to operationalize collaboration. Educational interventions targeting police have been advanced as a key operational strategy to accomplish this integration (Law Enforcement and HIV Network, 2013). As the number of and support for such educational initiatives across the world is growing, more research is needed to inform benchmarks, design, and evaluation. In particular, additional research is needed to parse out comparative effectiveness of law enforcement training interventions and to evaluate the role of policy, oversight mechanisms, incentives, and other wraparound interventions to encourage sustained behavior change advanced by the trainings.

Acknowledgments

Role of Funding Source

Funding for the data collection process was provided by the Open Society Foundations’ Sexual Rights and Health and International Harm Reduction Development Programs. Beletsky is also supported by grant number 2R37DA019829 (S.Strathdee, PI) from the National Institutes of Drug Abuse. Views expressed are of the authors and do not necessarily reflect the views of the National Institutes on Drug Abuse, the National Institutes of Health, The Open Society Foundations, or AFEW. These entities had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.

The authors are indebted to research participants, field staff of partner NGOs throughout Kyrgyzstan, and Alexandr Zelitchenko of the Central Asian Center for Drug Policy. Assistance of AFEW staff, especially Ulan Soronkulov and Aijan Dooronbekova proved invaluable. Research assistance provided by Gabrielle Ransford.

Footnotes

Contributors

Shumskaya conceived of the research and Beletsky, Thomas, Smelyanskaya and Shumskaya designed the study. Shumskaya supervised data collection. Artamonova conducted statistical analyses, with input from all other authors. Beletsky wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript.

Conflict of Interest

The authors report no conflict of interest connected to any goods or services described.

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