Targeted Outreach Project: Scaling up HIV Programming in Burma by Mobilizing Sex Workers

The Targeted Outreach Project (TOP) provides HIV prevention services, as well as social, civic, and educational programs, for sex workers and men who have sex with men in Burma. TOP's community-driven and evidence-based strategies have contributed to its success and scale up across the country. Furthermore, epidemiological data suggest that TOP has contributed to declining HIV incidence in Burma.

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Targeted Outreach Project (TOP)

By Melissa Ditmore, Ph.D.

Scaling up HIV Programming in Burma by Mobilizing Sex Workers

FSW drop-in center activity


FSW drop-in center activity.

The sun is setting in downtown Yangon, Burma’s largest city and former capital, and the streets are crowded. Staff of the Targeted Outreach Project—now known simply as TOP—walk to a karaoke bar, not to sing, but to visit a sex work venue. Karaoke bars have separate rooms for small parties, which can consist of a man and as many women as he hires to join him; sex is typically part of the experience. Eight young women are sitting on the floor of one of the rooms, which is cooled only slightly with a fan. Despite the heat, everyone is riveted by Ahn, who is showing these women female condoms, giving them information about sexually transmitted infections (STIs) and HIV, and sharing a small book—sized to fit inside a handbag—that has information and clear illustrations about the female reproductive system and pictures showing how to insert and use the female condom. Everyone passes it around. There are questions, and a few people want to ask questions in private.

These women live and work on the premises. There are so many women living on-site that when they want to come to TOP’s drop-in center (DIC) and clinic, TOP sends a driver whose vehicle can accommodate all the women who want to come to the clinic that day. Scenes like these are playing out not only in Yangon but in 18 cities across the country through TOP’s community outreach programs. Launched in Yangon in 2004 by Population Services International (PSI), TOP works through a strategy called “community mobilizing community.” TOP provides female sex workers (FSWs) and men who have sex with men (MSM) access to stigma-free, comprehensive health services, safe places to discuss issues that concern them, and education and information to increase their ability to earn a living— including opportunities to serve as staff members of TOP.

Careful documentation of TOP’s ability to reach the FSW and MSM communities and its success delivering services lead donors to deepen their engagement and support TOP’s expansion around the country. TOP has scaled up to 18 locations, reaching 70 percent of the 60,000 FSWs and 25 percent of the 240,000 MSM estimated to be in Burma (TOP, PSI/Myanmar, and USAID 2011), approximately 5 percent of whom sell sex (TOP and PSI/Myanmar staff 2012). TOP has proven to be a significant force in the fight against HIV in Burma, and is set to become increasingly more autonomous of its parent organization over the next few years.

Disclaimer: The authors' views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

Background

FIGURE 1. MAP OF TOP LOCATIONS ACROSS BURMA

FIGURE 1. MAP OF TOP LOCATIONS ACROSS BURMA

HIV prevalence in Burma is estimated at less than 1 percent, and the epidemic is considered to be maturing and in a declining phase. However, the populations reached by TOP—FSWs and MSM— bear more of the HIV burden in this concentrated epidemic (National AIDS Programme, UNFPA, UNAIDS and Global Fund Country Coordinating Mechanism 2011a, 2011b). It is estimated that approximately 5 percent of MSM, and nearly a quarter of transgender people, sell sex (TOP and PSI/ Myanmar staff 2012). Considering this, the National Strategic Plan & Operational Plan on HIV and AIDS includes a focus on sexually transmitted HIV, particularly among people at highest risk. This means addressing HIV vulnerability and transmission among sex workers and MSM. People who inject drugs (PWID) also suffer a high burden of HIV (National AIDS Programme, UNFPA, UNAIDS and Global Fund Country Coordinating Mechanism 2011a, 2011b), and PWID may overlap with sex workers of all genders and with MSM (FHI 2010).

Sex between men (though not between women) is criminalized in Burma, as is sex work. When asked why people sell sex, United Nations (UN) and nongovernmental organization (NGO) representatives and sex workers all referred to the economic situation in Burma. A comparison to Thailand, which shares Burma’s longest border, offers practical insight into the economic situation: “Someone born in Thailand can expect to live seven more years, have almost three times as many years of education, and save almost eight times as much as someone born in Myanmar [Burma]” (UNDP 2009).

High unemployment and widespread poverty limit the job options for MSM and uneducated women with few skills. Selling sex has low barriers to entry, but exposes sex workers to greatly increased risk of HIV and other health problems. The 2008 Behavioural Surveillance Survey reported that HIV prevalence among FSWs in Burma was 18.4 percent (HIV and AIDS Data Hub for Asia-Pacific 2010), with interaction between FSWs and drug users (National AIDS Programme Myanmar and WHO 2008). The HIV Sentinel Sero-surveillance survey of 2011 reported HIV prevalence of 9.4 percent among FSWs and that prevalence among MSM had declined from 28.8 percent among MSM in 2008 to 7.8 percent in 2011 (National AIDS Programme 2012c).(1)

“It’s different with TOP. When we come to TOP, the TOP staff are warm and take care of members. Other organizations are not like this—there is less care and more stigma.”
— Male sex worker

These data about prevalence do not account for deaths. Although it seems that sex workers who take the places of those who leave their métier or die are practicing safer behaviors, among MSM, it appears that safer behaviors have not caught on in the same way, and more work to combat the spread of HIV is necessary. Stigma and infrastructure weaknesses, as well as political conflict in some parts of the country, impede HIV prevention efforts (National AIDS Programme 2010, HIV and AIDS Data Hub for Asia-Pacific 2010).

TOP was started by PSI with support from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development (USAID) in 2004, after the Burmese government sought external assistance to address HIV. TOP’s goal is to improve the health and quality of life among FSW and MSM communities in Burma. PSI/Myanmar and TOP define improved health as reduced burden of disease, including HIV, STIs, and maternal and child mortality. Improved quality of life refers to:

  • Increasing access to social support space
  • Reducing stigma and discrimination
  • Enabling a community voice and community advocacy
  • Improving access to quality health care services.

PSI/Myanmar’s research team started with mapping exercises to identify where sex workers and MSM congregated. TOP then hired and trained outreach workers and peer educators from among the FSW and MSM communities to encourage members of these groups to visit their DICs for health care services, including reproductive health and HIV-related services. Outreach workers and peer educators make up the majority of TOP’s 322 staff. It is estimated that there are 60,000 FSWs in Burma, and TOP reached 47,215 in 2010. It is also estimated that there are 240,000 MSM in Burma, and TOP reached 54,839 in 2010 (TOP, PSI/Myanmar, and USAID 2011); approximately 5 percent of the 54,839 sell sex (TOP and PSI/Myanmar staff 2012). TOP builds on services and strategies to enable FSWs and MSM to lead healthier, more productive lives. These strategies include delivering more than the minimum package of services for HIV prevention, treatment, care and support. The minimum package typically includes outreach and peer education, voluntary and confidential HIV counseling and testing (VCCT), targeted media, condom distribution, STI treatment, materials for safe injecting for PWID, and links to care and treatment (Bessinger et al. 2007).

1 HIV data among MSM is collected without disaggregating information about male and transgender sex workers.

Implementation

FSW field activity


FSW field activity.

TOP offers a range of services to MSM and FSWs within its DICs and advocates for sex workers at the local, national, and international level. TOP reaches out to local authorities, participates in planning national HIV activities and strategies, and is active in international networks. TOP is respected throughout the region; Kay Thi Win, TOP’s Program Manager for FSWs, was elected to a high-level position representing sex workers throughout the Asia Pacific region.

A critical element of the services at DICs is free medical care: the sex workers who visit TOP are primarily low-income sex workers and many would not seek care for which they had to pay. TOP offers services beyond HIV and beyond the minimum package of services for HIV (see Box 1) because many factors affect a person’s risk and vulnerability to HIV. TOP also works to empower MSM and sex worker communities, an approach that has been linked to greater effectiveness in HIV programming with sex workers (Shahmanesh et al. 2008).

Each service was developed in response to the situations participants face. Thus, community members influence decisions about which services to provide and how to implement services. For example, after a participant experienced irregularities upon arrest, TOP engaged an attorney to learn about the laws used against sex workers and the penalties associated with these statutes. An attorney is sometimes consulted by TOP staff and participants. The lending program was conceived of, designed, and is entirely implemented by participants.

TOP is now working to be able to offer screening for cervical cancer to FSWs because of participant demand.

BOX 1. TOP DELIVERS
MORE THAN JUST
MEDICAL SERVICES

  • Outreach and peer education
  • DIC safe space
  • Sexual and reproductive health services including short- and long-term birth control
  • STI testing and treatment
  • On-site laboratory in some locations
  • VCCT with same-day test results
  • Referrals to public and private providers of treatment for HIV-positive people
  • Testing, treatment, and care for opportunistic infections and tuberculosis
  • Home-based care including nutrition for HIV-positive people provided by peers
  • Legal advocacy and education
  • English language and computer classes
  • Vocational training
  • Lending program
  • Assistance with identity papers, opening bank accounts, and other official interactions.

Input from participants is taken very seriously: when participants said that they do not want to be perceived as targets, but as participants, the name of the project was changed from Targeted Outreach Project simply to TOP.

Drop-in center–based services: All services aside from home-based care are provided at the DIC locations. DICs are intended to be stigma- and discrimination-free zones and they offer friendly services for these marginalized populations. When scaling up in a new location, TOP seeks settings that offer both shared and separate space. For example, TOP’s DIC in Yangon includes areas where MSM and FSWs can interact, but also separate buildings where MSM and FSWs can gather in more private groups or work on specific campaigns. In other locations, sometimes the MSM and FSWs gather on separate floors. FSWs and MSM have found common ground as well as benefits to being allied, in addition to the administrative advantages conferred by co-location. In general, FSWs face different issues from MSM—for example, MSM overall are not a low-income community. TOP and PSI estimate that approximately 5 percent of TOP’s MSM clients are transgender sex workers and male sex workers, who—like FSWs—are typically low-income (TOP and PSI/Myanmar staff 2012). Sex workers of all genders benefit from sharing space and working together, sharing information and strategies to promote 100 percent access to condoms and personal lubricant.

DIC health services are provided free of charge and in a respectful environment. Multiple services are available at the DICs, and this has contributed to increased access and uptake of services because participants do not spend extra time and money on transportation between service providers and do not need to take additional time away from work to visit multiple locations. TOP participants reported that more sex workers seek health care more frequently, instead of putting off seeking medical attention because of financial concerns, now that TOP offers free health care for FSWs and MSM. TOP is funded primarily by PEPFAR, with additional funds from the UN; the Global Fund to Fight AIDS, Tuberculosis and Malaria; and the Three Diseases Fund.

Economic motivations and small loans: TOP staff and participants reported that every woman engaged in sex work needed to support herself or her family. Hence the small lending program, which helps TOP’s FSW participants get through a crisis without engaging in risky behavior in order to get money quickly. For example, when a woman is arrested or has other expenses, she can apply for a loan and the application is considered by a committee. Two guarantors are required for loan approval and repayment is expected within six months. To date, the repayment rate so far is 100 percent with no defaults since this component of the programs started.

BOX 2. MALE SEX WORKERS ALSO BENEFIT FROM TOP

Joe, an outreach worker for TOP’s MSM program, meets other TOP and PSI staff at a cruising point, near a bridge where men meet other men to hook up for sex. Joe speaks to all the people he knows, MSM and especially the men who sell sex, who make up about 5 percent of TOP’s MSM clients.

Joe knows everyone and it is clear that he is the most popular man in the cruising area. So though he’s only going a few blocks—a couple of minutes’ walk—Joe arrives 20 minutes later. When he arrives, Joe is immediately approached by men on the bridge who know him and who want condoms and personal lubricant to prevent HIV and STIs.

Social, civic, and educational programs: There is an impressive level of foresight entailed in thinking ahead about wanting to have children, wanting to find other work, and the additional costs of treatment for infections. The importance of this foresight can be difficult to impress upon people working to survive day-to-day, as many sex workers are doing. For this reason, TOP offers social programs including education, information, and training which can help sex workers improve their health, their income, and their livelihood.

DICs hold social activities such as Saturday Clubs for people living with HIV/AIDS (PLHIV) and parties. There is space for relaxing with peers, allowing time to share information. One participant described the incorporation of “stealth messages” and information into social activities, saying, “When we have other emotional issues we have funny things and entertainment and we are happy be involved in those sessions, and they have messages and information about health and HIV.”

The Saturday Clubs are more than social events: they are the forefront of community-based care for PLHIV in Burma, spearheaded by FSW and MSM. Social activities as a form of community-based care are important not only for TOP specifically, because TOP has a high number of HIV-positive participants and staff, but also around the country as additional treatment slots become available for HIV-positive people. The expansion of treatment in Burma makes these community-based support systems essential for adherence to and understanding of treatment.

TOP also provides education that can increase male, female, and transgender sex workers’ ability to earn a living. For example, TOP offers English language and computer instruction on-site at the DICs. The program offers information and advice about obtaining national identity cards, which enable participants to travel freely throughout the country, open bank accounts to save money, and attend school. Participants linked these skills and information to improved health and career opportunities. As one FSW explained, “If we save money, then we have money and we can take fewer clients and this is good for our health. If we have a passport and an opportunity for a job in another [HIV program] agency, we can have job options outside our country. We need the national identity card for jobs in the country, too.”

“Before TOP, I knew about condoms and HIV but I did not use them regularly. Then, from TOP I gained knowledge, and even if I have regular clients, I use condoms even with them and with my husband because we know that we can get STIs from regular clients and we need to protect ourselves and treat ourselves on time. Otherwise, STIs can lead to problems when we marry and want children, so we use condoms.”
— Female sex worker

Vocational training for FSWs and MSM is intended to provide skills that can allow participants to run a small business, such as selling flowers or being a stylist because, as one participant pointed out, “Many bosses do not want people living with HIV/ AIDS or sex workers.” Planning for the future was another important aspect of vocational training. One sex worker explained, “Sex work is not viable for the whole life span; it is not a living for old people. Vocational training will help people continue to work.”

TOP’s Strategies

FSW social event day


FSW social event day.

TOP’s success builds on multiple elements. In addition to the comprehensive medical and social services described on previous tabs, the program relies on specific strategic components. These include community involvement in project activities and planning as well as rigorous data-gathering to capitalize on successes and plan for future programming.

TOP’s philosophy of community involvement: TOP is founded on community involvement in every program activity, including deciding what programs to undertake, determining how to implement them, and ensuring that hiring starts in the community. To begin with, TOP is committed to hiring sex workers and MSM in professional, paid staff positions. This allows TOP access to the insider knowledge of its target community, which is best positioned to identify new needs and emerging problems. It is an approach described by TOP’s Kay Thi Win as “bottom-up decision-making with different levels of people and negotiation.”

Programming decisions begin with a consultation among staff and participants. Decisions are made in a consensus process with those affected. Staff first discuss pending decisions with management and team leaders; if the decision involves or affects the community, then discussion with peer educators and participants follows. Another round of discussions may follow; the process can be lengthy, but the resulting support from and to the community is worth the effort.

Building community capacity — TOP is committed to the “peer progression model,” hiring from the FSW and MSM communities. Because of its hiring members of the community, TOP has constituted a first step for professional training for many staff members. More than 20 TOP outreach workers and peer educators have moved on to work for other organizations, creating openings for other sex workers and MSM to be hired. TOP’s capacity building and training for community members and employees has enabled TOP to promote and hire community members for other positions, so that only those positions requiring specific licensing (such as doctors) or very technical skills (such as data analysis or bookkeeping) are held by people who are not members of the community.

Capacity building is now under way to help community members learn the skills necessary to undertake more of the tasks requiring technical knowledge. These hiring and capacity-building practices ensure that TOP includes FSWs and MSM at all possible levels, involves the community in decision-making, and makes sure that staff interests align with those of the community. This also ensures that there are potential staff people for new locations, as expansion to new locations is determined by the needs of sex workers and MSM as reported by current participants.

FIGURE 2. HIV PREVALENCE (%) AMONG FSW AND MSM, 2005–2011

HIV prevalence dramatically decreasing

Strategic data-gathering to inform planning: To determine what will promote its health agenda and what will be relevant for the people who use its services at each site, TOP works with PSI/Myanmar on mapping, clinic, and DIC data; population size estimation; and PSI’s unique Tracking Results Continually (TRaC) system. Strategic information-gathering helps with advocacy, planning, and—importantly—demonstrating the program’s performance and effectiveness. Data demonstrating TOP’s effectiveness, such as the decline in syphilis and HIV among TOP participants, has facilitated the TOP scale-up by showing the Burmese government that the project had achieved concrete results. Also, donors are eager to support evidencebased and proven effective programs like TOP.

BOX 3. TOP’S PEER PROGRESSION MODEL: THE CLINIC ASSISTANT

TOP is committed to hiring sex workers and MSM in professional, paid staff positions. While most community members start as peer educators or outreach workers, Sue was hired to be the clinic assistant. She sought the position because she wanted to reduce her vulnerability to arrest. She said, “I worked on the street, and I saw peer workers and we talked and they gave me IEC [information, education and communication] materials. Then I came to TOP and got services but I did not want to work here. Then I was arrested. I had to stay in the prison, and when I came back, I worked and was arrested and went back to prison, and to the rehabilitation center. When I came back from there, I was afraid while working.

Sue clearly needed work that would not leave her vulnerable to arrest. However, without education and experience, her options were very limited. TOP understood that it would have to train any community member hired for this position, which involves handling medical samples and lab equipment such as the centrifuge. They interpreted Sue’s situation as offering exceptional motivation and hired her. “I came to TOP regularly and when there was an opening, I applied and I got the job. I had a lot of training to be the clinic assistant.” Now Sue has successfully trained others in clinical procedures and how to use the equipment.

Mapping to identify need — TOP conducts periodic mapping exercises to ensure that programs are located where sex workers and MSM can reach them, and to be sure that activities are expanded to new locations where there is demand for health services for FSWs and MSM.

Tracking population — Population size estimates (PSEs) are also important when starting in a new location because they help measure the number of people in the target population.

TOP conducted PSEs of FSWs and MSM in each new location. A PSE is not a rigorous study, but a reflection of a given area at the time the estimate was undertaken, and of the dedication and skills of the local investigator and the data collection team. Ideally, a PSE should be conducted over a few days to avoid overcounting, though this quick execution makes it difficult to conduct PSEs in some settings, such as large cities with many sex workers and MSM hotspots. Nevertheless, PSEs are useful tools for predicting staffing and logistical needs—for example, how many outreach workers and peer educators are needed, and how many clinic visits and tests for STIs and HIV can be anticipated. Then staffing can be fine-tuned according to experience.

For instance, PSEs of FSWs were undertaken in TOP’s catchment areas in late 2011. Key informants in five cities where TOP has a DIC and peer outreach activities identified suspected new “hotspots,” including information about respondents’ places of origin. The results reflected high mobility among FSWs, including among small townships. For example, the estimated number of FSWs in Moulmein [Mawlamyine] township, according to key respondents, ranged from 1,127 to 1,708 during the 30 days of the exercise (PSI/Myanmar 2011). These estimated numbers can be used to determine how many outreach workers and peer educators may be needed at this location, and later, if seasonal or other fluctuations are found—in keeping with the high mobility documented—staff numbers can be adjusted at the site.

Data-gathering — TOP collects data on daily clinic and DIC attendees, services sought, and referrals made, as well as clients contacted daily through outreach workers and peer educators; these data are analyzed by PSI/Myanmar’s research team. In addition to clinic and outreach information, PSI/Myanmar has developed a series of questions as part of its TRaC data analysis intended to identify determinants of behavior over time and the factors that influence specific behavior. The analysis found, for example, a statistically significant link between having plans for the future and consistent and correct condom use. Among survey participants, both MSM and FSWs, those who believed that HIV infection would undermine their goals for the future were much more likely to report consistent condom use (Tin Aung 2012). TOP frequently uses the concept of future plans in its outreach and education materials, including, for example, a cost-benefit analysis comparing the benefits of more money for unprotected sex today versus lost working time and medical costs for infections over the longer term.

TOP and Burma’s HIV Epidemic

MSM drop-in center activity


MSM drop-in center activity.

Syphilis also trended downward from 5.5 percent in 2008 (TOP, PSI/Myanmar, and USAID 2011) to 3.9 percent among FSWs in 2011 (National AIDS Programme 2012c) and from 14.1 percent in 2008 (TOP, PSI/Myanmar, and USAID 2011) to 2.5 percent among MSM in 2011 (National AIDS Programme 2012c). Since STIs are epidemiologically linked to HIV transmission, their diagnosis and treatment are important elements in HIV prevention.

While HIV prevalence has declined and these achievements are substantial, the numbers remain quite high. Furthermore, without data about deaths and people who leave programs and sex work due to illness, it is unclear how much HIV has really declined among FSWs and—especially—among MSM in Burma. Despite declines in prevalence, TOP’s work remains extremely necessary. HIV programming for these key populations remains a priority in the National Strategic Plan to address HIV in Burma (National AIDS Program, UNFPA, UNAIDS and Global Fund Country Coordinating Mechanism 2011a, 2011b).

Numerous actors have contributed to the decline of HIV and STI prevalence among MSM and FSWs, including TOP, which has played a major role in part due to its size and scale as the largest organization working with these populations in Burma. While it is not possible to discern exactly what is attributable to any single program, it is probable that such a decline has been accomplished at least partly because of TOP’s. NGOs have more community access than the government and can reach more members of most-at-risk groups, making NGOs a critical part of the service delivery provision as well as the data collection scheme for bio-behavioral surveillance in Burma. Indeed, a PSI doctor explained that the National AIDS Program has used PSI and TOP data since 2006 to report to the Department of Health on STIs, treatment referrals, and VCCT. TOP will participate again in the next round of national surveillance, including collecting blood samples.

Evaluations have praised TOP’s methods. One such evaluation of HIV prevention programming in Burma—an evaluation to which TOP contributed— found several elements that led to successful programs:

  • Offering multiple components of the minimum package at one site contributed to the high intensity of service.
  • Working with partner organizations further added opportunities for interactions with outreach workers, peer educators, and other service providers, contributing to intensity of service use.
  • Core elements of the minimum package, print media exposure, and interactions with outreach workers were associated with more consistent condom use among MSM and FSWs (Bessinger et al. 2007).(2)

These are all components common to the TOP program.

2 While condom use among FSWs and their clients seems to have matured, sustained campaigns may be necessary to maintain these gains (Bessinger et al. 2007).

What Worked Well

Annual award for TOP site


Annual award for TOP site.

Community involvement and ownership: Community involvement has led to a deep feeling of ownership of TOP, which is the key to the project’s success. “It’s the community themselves who have led the mobilization process which has largely brought the TOP program to scale and to its success today,” said PSI/Myanmar Program Officer Celeste Jennings.

Reaching and mobilizing marginalized people like sex workers is best accomplished through their direct involvement in prevention programming; without their involvement, HIV programming is inherently limited. TOP involves community members in the most direct way possible—by hiring and promoting them, and by building their capacity to run their own affairs.

Community involvement requires commitment to inclusion at every possible level. This can be challenging, but offers great rewards. TOP’s community-driven approach has facilitated the program’s extensive reach across Burma and enhanced its contribution to the impressive turnaround of the HIV epidemic in the country.

Replicable, community-driven peer progression model: TOP’s community-oriented model is replicable, provided that implementers and administrators wholeheartedly believe that community members bring valuable input. TOP’s successful approach highlights that the community perspective should not only be welcomed, but embraced and utilized as the expert perspective on the situations faced by the groups being addressed. Another priority in replicating TOP’s approach is to engage in long-term capacity building as necessary for community members to take on management and decision-making responsibilities. This investment in personnel engenders community members’ sense of ownership of the program and activities.

TOP’s specific actions in response to the HIV epidemic in Burma may not be appropriate everywhere, but TOP’s general approach consulting and involving community members can be replicated almost anywhere and with almost any population that exists as an identifiable community. Sex workers have responded well to being approached respectfully for collaboration on matters that affect them. The community members can help determine what should be done and can help administrators and managers learn critical information such as where to conduct outreach, how many people might seek services, and what services are desirable. TOP’s success shows that sex workers add value to programs when they are included not only as “targets” but as paid staff doing work valued by their communities. While consulting members of the community you seek to address is always a good start, a community-based approach may not be as successful in places where the group you seek to address is widely dispersed or very disparate and does not form a cohesive or identifiable community; in such cases, community building may be a prerequisite.

Evidence-based programming: TOP has benefited from PSI/Myanmar’s research expertise in analyzing what works, which TOP has scaled up and implemented, for example, focusing on future goals as a reason to protect oneself and others from HIV. Furthermore, offering evidence of TOP’s effectiveness is a great asset in discussions with the government and donors about ways to address HIV and how to support these efforts. PSI/ Myanmar’s research team assisted TOP in the development of methods for mapping and PSE, and the identification of sound strategies for HIV prevention education such as attention to future plans and demonstrating the need to prevent infection if one is a PLHIV. Additionally, PSI/ Myanmar’s research team helped develop the data collection methodology for the clinic and DIC data. PSI/Myanmar’s analysis of the data collected by TOP demonstrated the correlation between TOP’s activities and the decline in STIs and HIV among MSM and FSWs since TOP started delivering services.

Environments free of stigma and discrimination: TOP DICs are intended to offer a welcoming, friendly space, free of stigma and discrimination, to help create an enabling environment for HIV prevention programming. However, it took time, persistence, and close work with staff members to create an accepting environment.

Sensitizing staff — Some staff members initially refused to ride in the same car with sex workers. While this kind of overt discrimination was not tolerated, less overt stigma and discrimination was more difficult to address. Initially, many staff members were not comfortable discussing MSM and sex work and the methods to prevent HIV, especially correct condom use between men. PSI/ Myanmar staff had to be educated and socialized to be able to discuss MSM and sex worker issues, work with MSM and sex workers, and promote consistent, correct condom use. This sensitization took time, but was essential to TOP’s success in addressing HIV and STIs.

A doctor with PSI/Myanmar described the changes that have happened, saying, “I was not good around MSM but now they are my friends. The point is for the organization and local staff, the attitudes have changed dramatically over the years. The female staff, they used to be giggly and embarrassed about the demonstrations and how to use condoms, but now it is routine. Also, MSM and FSW are well integrated into the structure. They are just other staff.”

Ensuring that TOP facilities offer clients a safe, discrimination-free environment has in turn strengthened the trust of TOP’s client communities. Sex workers described not only the acceptance and friendliness of the health care providers but also the quality of both the clinic and social services. As one participant shared, “When we come here from home and we have problems with family and money, we are here with our friends and we go to work. This is a safe space. We can shower and dress and get ready for work” without being looked down upon.

Valuing community input and experience — The opinions of community members are highly valued and used in programmatic decisions, including maintaining a friendly and welcoming environment. For example, when a doctor was hired but then was reported by participants as being insufficiently friendly to community members, another doctor was hired to work directly with community members. When possible, members of the community, such as doctors who are MSM, have been hired. In this example, the other doctor was reassigned within PSI but outside TOP.

In some cases, hiring sex workers may require long-term capacity building. While this can be more resource-intensive at first, it contributes to community ownership and creates employment opportunities for people who might not have many job options.

Demonstrating the competence of MSM and sex workers — The peer progression model also helps to reduce stigma and discrimination beyond TOP sites. Sex workers and MSM demonstrate that they can learn information, skills, and techniques that they can use to be highly effective outreach workers and peer educators, and that they can implement programming. Their experience as members of the target populations and the interpersonal skills developed both by marginalized populations and in sex work contribute to their abilities as outreach workers and peer educators. The proven ability to implement effective programs has enabled TOP peer educators and outreach workers to become employees with other programs, creating job openings for other TOP participants. In this way, TOP addresses a need within the participant community in that there is a dearth of professional jobs that they can apply for. The peer progression model is one way to help community members develop skills that may help them get other jobs in the future, as demonstrated by the numbers of TOP employees who have moved to employment with other organizations. Furthermore, this also contributes to the reduction of stigma and discrimination against sex workers and MSM at other organizations and more broadly.

However, sex work remains highly stigmatized and sex workers feel this stigma when they interact with people of higher status; this remains an issue when TOP participants are referred elsewhere for services. For this reason, when TOP refers people to other agencies, a TOP staff person will often go with them. Results are better when TOP staff accompany participants to other agencies because the presence of another service provider, the TOP staff person, deters stigmatization and denial of services to sex workers.

Challenges

Scaling up is time-consuming and resource-intensive: TOP endured numerous stops and starts during the process of scaling up. While expanding from 1 to 18 locations, in each location the program had to negotiate relationships with the local authorities, locate appropriate venues for the DICs, and build enough clientele to justify hiring medical personnel. These steps take time: developing relationships with local authorities, for example, requires time to identify the right people to work with, sometimes initiating relationships with two or even three individuals before finding the right fit. Staying focused on each step requires great perseverance, and TOP expressed extreme gratitude to its donors for sticking by the project during the difficult, sometimes stalled, process of scaling up.

Obtaining government buy-in: Donors have encouraged TOP and its partners, including government agencies, to allow TOP to continue and to scale up its critical public health work with key populations, even when those populations engage in behavior that is against the law. The government has limited capacity to offer point-of- care HIV-related services, so most services are provided by NGOs and supported with international donor funding. Because of the strong data collection and analysis by TOP and PSI/ Myanmar demonstrating TOP’s deep reach into the FSW and MSM communities and ability to deliver services, the government recognizes the public health significance of TOP’s work. The government has included TOP data in government data since 2006. For example, TOP collects blood samples from FSWs and MSM for bio-behavioral and seroprevalence surveys conducted in Myanmar. The government sees TOP as a valued partner in these efforts. TOP relies on the government to support its work—without such buy-in, the government could simply close TOP. However, this buy-in is promoted by international agencies and included in the National Strategic Plan (NSP). International donor support for this work has made a great difference in TOP’s ability to negotiate its position within the NSP.

Reaching new levels of organizational management: This is an exciting but also challenging time for TOP because TOP is set to spin off from its parent organization, PSI/Myanmar, over the next few years, according to its agreement with USAID, TOP’s largest donor. TOP staff manage the DICs, and so it is clear that they will be able, with training and capacity building, to hire the right people to manage the tasks currently managed by PSI/Myanmar or to manage agreements with PSI/Myanmar in continuing partnership. Nevertheless, questions about how autonomy and independence will be maintained remain to be answered. TOP staff may require further capacity building in order to manage financial reporting, data analysis, and fundraising. TOP plans to continue using the community-based, bottom-up decisionmaking process that has contributed to the high level of participation and ownership by sex workers.

Recommendations

Involve members of the community being addressed in decision-making: Key affected populations should be involved in the conceptualization and implementation of any HIV-related programming that targets or affects them. Grassroots efforts enabled TOP to reach “unreachable populations” such as FSWs and MSM, including transgender people and men who sell sex.

TOP’s relationships with local authorities, the National AIDS Program, and the trust of donors combined to afford TOP great autonomy to undertake a community-based, grassroots approach to HIV programming with sex workers and MSM. Autonomy in programming design and implementation enabled TOP to develop programming solely in consultation with program participants from key affected populations and epidemiological and social marketing experts, rather than in response to an externally imposed agenda.

Involve members of the community in service provision, especially testing: TOP’s staff includes certified technicians whom the government allows to conduct HIV testing. In addition to the counselor who conducts the testing, peer educators accompany community members to be tested for HIV at TOP sites and at governmentrun clinics. These relationships encourage FSWs and MSM who are at higher risk of HIV than the general population but who simultaneously stay away from stigmatizing situations, including in health services, to seek testing. Testing is important because it is the gateway to treatment, care, and support for PLHIV.

Reach out to new sex workers as soon as possible: HIV prevalence among young FSWs (aged 15-19) has declined since TOP started, from over 40 percent in 2005 to 10.4 percent in 2011 (National AIDS Programme 2012c). But even with TOP’s successful outreach to FSWs, 10.4 percent HIV prevalence among young FSWs (aged 15–19) in Yangon, the largest city, is alarming, and is slightly higher than in 2009 and 2010 even as rates of HIV among other age groups declined (National AIDS Programme 2012b). This reflects the vulnerability of people new to sex work to HIV, which has been documented in other settings (Kraus 2011; Silverman 2011; Sopheab et al. 2008). In light of this vulnerability at the time of beginning sex work, it is critical to reach the newest entrants to sex work and to promote HIV prevention among this group early and often. To do this may require including NGOs like TOP but also management and other sex workers at venues with staff who may be new to the trade to promote HIV prevention skills among new sex workers.

Perseverance is crucial for success: TOP has received great accolades, but few people have heard about the great perseverance required during the past eight years in order to scale up the program around the nation. One of the lessons TOP offers other projects is to persevere and stay focused on meeting the needs of your participants. They are the key to the drive needed to push forward despite the obstacles that invariably arise. TOP has found solutions to each challenge, but not without a high level of determination. FSW Program Manager Kay Thi Win described TOP’s persistence, explaining that each time TOP staff encounter an obstacle, they strategize and try to identify three different ways to overcome it. This can entail long waits to determine what to do, whom to approach, and how to approach them; give each attempt time to work; and then come up with and try another strategy. At each new location, successful scale-up required working with new local authorities and business owners and managers—each interaction presenting a possible challenge requiring persistence.

In some cases, resolution has taken years. And in those cases, TOP was able to envision reasons to persist and take hope from the possibilities and previous triumphs. The key to successful persistence is to remain optimistic and focused in the face of adversity, while simultaneously making realistic assessments of what to try next.

Future Programming

TOP has contributed to the success of the struggle against HIV in Burma, but there is more to be done. Citing TOP’s services, a male sex worker said, “We want TOP to be sustained. We have seen other groups come and work and then they leave, and we don’t want that to happen to TOP.” Its community management focus contributes to TOP’s potential sustainability, but long-term capacity building or connections to people and organizations that can assist with fundraising and data analysis are also critical to success.

TOP’s great accomplishments in difficult circumstances inspire optimism about what can be accomplished not only by TOP but elsewhere. The program’s approach of peer outreach, community mobilization, and DIC-based services can serve as a model for other programs.

References

Bessinger, Ruth, Maung Maung Nyein Chan, Kim Longfield, Tin Aung, and Habibur Rahman. 2007. Evidence for a successful implementation of the minimum package of HIV prevention interventions in Myanmar. USAID, Measure Evaluation & PSI. Outside link (accessed May 2012)

Family Health International (FHI). 2010. Young People Most at Risk of HIV: A Meeting Report and Discussion Paper from the Interagency Youth Working Group, U.S. Agency for International Development, the Joint United Nations Programme on HIV/AIDS (UNAIDS) Inter-Agency Task Team on HIV and Young People, and FHI. Research Triangle Park, NC: FHI, 2010. Outside link (accessed May 2012)

pdf HIV and AIDS Data Hub for Asia-Pacific (August 2010). Sex Work & HIV Myanmar. Outside link (PDF, 543 KB) (accessed May 2012)

Kraus, Steve. 2011. “Regional Overview of Progress on Universal Access in Asia-Pacific.” Presentation at Getting to Zero, Bangkok, Thailand, March 30–31, 2011.

National AIDS Program, UNFPA, UNAIDS and Global Fund Country Coordinating Mechanism. 2011a. Myanmar National Strategic Plan & Operational Plan on HIV and AIDS 2011- 2015 Concise Version. Outside link (accessed May 2012)

National AIDS Program, UNFPA, UNAIDS and Global Fund Country Coordinating Mechanism. 2011b. Myanmar National Strategic Plan & Operational Plan on HIV and AIDS 2011-2015 Operational Plan. Outside link (accessed May 2012)

National AIDS Programme. March 2012a. Global AIDS Progress Report Myanmar. Outside link (accessed May 2012)

National AIDS Programme. Presentation to the Sexual Transmission Working Group, Naypidaw, Burma, April 2012b. Slides.

National AIDS Programme. 2012c. Results of HIV Sentinel Sero-surveillance 2011 Myanmar. Yangon: World Health Organization.

National AIDS Programme. 2010. UNGASS Country Progress Report, Myanmar. Outside link (accessed March 2012)

pdf National AIDS Program and World Health Organization. National Behavioral Surveillance Survey 2007-2008 Report Myanmar on Injecting Drug Users and Female Sex Workers. Yangon: World Health Organization. Outside link (PDF, 2.13 MB) (accessed May 2012)

PSI/Myanmar. “Estimation of FSW population size.” Internal presentation, November 2011. Slides.

Shahmanesh, M., V. Patel, D. Mabey, and F. Cowan. 2008. Effectiveness of Interventions for the Prevention of HIV and Other Sexually Transmitted Infections in Female Sex Workers in Resource Poor Setting: A Systematic Review. Tropical Medicine and International Health 13:659–79.

Silverman, Jay G. 2011. Adolescent female sex workers: invisibility, violence and HIV. Archives of Disease in Childhood 2011;96:478–481.doi:10.1136/adc.2009.178715.

Sopheab H., G. Morineau, J. J. Neal, V. Saphonn, and K. Fylkesnes. 2008. Sustained high prevalence of sexually transmitted infections among female sex workers in Cambodia: high turnover seriously challenges the 100% condom use program. Infectious Diseases 8:167.

Tin Aung (Director of Research, PSI/Myanmar). Interview. May 2012.

TOP and PSI/Myanmar staff. Interviews. May 2012.

TOP, PSI/Myanmar, and USAID. 2011. “Addressing Challenges: HIV-related Rapid Testing in Burma.” Presentation to USAID and AIDSTAR-One, Bangkok, Thailand, April 27, 2011. Slides.

United Nations Development Programme (UNDP). 2009. Overcoming Barriers: Human Mobility and Development. New York: Palgrave Macmillan. Outside link (accessed May 2012)

Acknowledgments

The author would like to thank Habib Rahman and TOP staff, clients, and partners for sharing their stories and experiences with TOP. The author would also like to thank PSI/Myanmar staff and representatives of UN agencies and donor agencies who shared their opinions and experiences working with TOP. ThuVan Dinh with USAID/ Burma, Cameron Wolf and Clancy Broxton with USAID/Washington, and Heather Bergmann, Helen Cornman, Stephanie Joyce, Repsina Chintalova- Dallas with AIDSTAR-One offered important editorial input.

Recommended Citation

Ditmore, Melissa, Ph.D. 2012. Targeted Outreach Project (TOP): Scaling up HIV Programming in Burma by Mobilizing Sex Workers. Case Study Series. Arlington, VA. USAID’s AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1.