title: Policy reform to shift the health and human rights environment for vulnerable groups: the case of Kyrgyzstan's Instruction 417.
abstract: BACKGROUND
  Police activities shape behavior and health outcomes among drug users, sex workers, and other vulnerable groups. Interventions to change the policing of drug consumption and sex work in ways that facilitate public health programming and respect for human rights have included policy reforms, education, and litigation. In 2009, the Kyrgyz government promulgated "Instruction 417," prohibiting police interference with "harm reduction" programs, re-enforcing citizen rights, addressing police occupational safety concerns, and institutionalizing police-public health collaboration.
  
  
  OBJECTIVE
  Although ample evidence points to gaps between intended and actual impact of policy and other structural interventions, there is little research on the impact of initiatives designed to align policing, health, and human rights. We conducted a police officer survey to assess links between Instruction 417 knowledge and legal and public health knowledge, attitudes towards harm reduction programs, and intended practices targeting vulnerable groups.
  
  
  RESULTS
  In a 319-officer sample, 79% understood key due process regulations, 71.1% correctly characterized law on sex work, 54.3% understood syringe possession law, while only 44.4% reported familiarity with Instruction 417. Most (72.9%) expressed positive attitudes toward condom distribution, while only 56% viewed syringe access favorably. Almost half (44%) agreed that police should refer vulnerable groups to disease prevention programs, but only 20% reported doing so. In multivariate analysis, knowledge of Instruction 417 was associated with significantly better knowledge about (aOR=1.84, 95%CI: 1.12-3.00) and attitudes towards harm reduction programs (aOR=3.81, 95%CI:1.35-10.75), and knowledge of due process for the detention of sex workers (aOR=2.53, 95%CI:1.33-4.80). Younger, junior officers and those in rural areas may not be well-informed about the policy.
  
  
  CONCLUSIONS
  While reflecting positively on Instruction 417 as a structural approach to aligning policing and public health, this analysis highlights gaps in policy dissemination and calls for further research to assess street-level impact of interventions on the health and human rights environment for vulnerable groups.
authors.affiliation: School of Law and Bouvé College of Health Sciences, Northeastern University, Boston, MA, USA. Leob@alumni.brown.edu
authors.forename: Leo
authors.initials: L
authors.lastname: Beletsky
authors.forename: Rachel
authors.initials: R
authors.lastname: Thomas
authors.forename: Marina
authors.initials: M
authors.lastname: Smelyanskaya
authors.forename: Irina
authors.initials: I
authors.lastname: Artamonova
authors.forename: Natalya
authors.initials: N
authors.lastname: Shumskaya
authors.forename: Aijan
authors.initials: A
authors.lastname: Dooronbekova
authors.forename: Aibek
authors.initials: A
authors.lastname: Mukambetov
authors.forename: Heather
authors.initials: H
authors.lastname: Doyle
authors.forename: Rebecca
authors.initials: R
authors.lastname: Tolson
mesh_terms: D000328:Adult; D005260:Female; D015658:HIV Infections / Q000517:prevention & control*; D006806:Human Rights; D006801:Humans; D007707:Kyrgyzstan; D008297:Male; D016495:Police; D011640:Public Policy; D011477:Sex Work; D015819:Substance Abuse, Intravenous / Q000453:epidemiology; D011795:Surveys and Questionnaires; D035862:Vulnerable Populations