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AIDSTAR-One Case Study: Targeted Outreach Program Burma


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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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AIDSTAR-One Case Study: Targeted Outreach Program Burma

  1. 1. aidstar-One | CASE STUDy SERIES December 2012Targeted Outreach Project (TOP)Scaling up HIV Programming in Burma by Mobilizing Sex Workers T he 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, TOP/PSI/Myanmar 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 isFsW drop-in center activity 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 whoBy Melissa Ditmore, Ph.D. 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.aidstar-OneJohn Snow, Inc. This publication was made possible through the support of the U.S. President’s1616 North Ft. Myer Drive, 16th Floor Emergency Plan for AIDS Relief (PEPFAR) through the U.S.Agency for InternationalArlington, VA 22209 USA Development under contract number GHH-I-00-07-00059-00, AIDS Support andTel.: +1 703-528-7474 Technical Assistance Resources (AIDSTAR-One) Project, Sector I,Task Order 1.Fax: +1 703-528-7480 Disclaimer: The author’s views expressed in this publication do not necessarily reflect the views of the United Agency for International Development or the United States Government.
  2. 2. aidstar-One | CASE STUDy SERIESCareful documentation of TOP’s ability to reach Figure 1. Map OF tOp lOcatiOnsthe FSW and MSM communities and its success acrOss BurMadelivering services lead donors to deepen theirengagement and support TOP’s expansion aroundthe country. TOP has scaled up to 18 locations,reaching 70 percent of the 60,000 FSWs and 25percent of the 240,000 MSM estimated to be inBurma (TOP, PSI/Myanmar, and USAID 2011),approximately 5 percent of whom sell sex (TOPand PSI/Myanmar staff 2012). TOP has provento be a significant force in the fight against HIV inBurma, and is set to become increasingly moreautonomous of its parent organization over thenext few years.BackgroundHIV prevalence in Burma is estimated at less than1 percent, and the epidemic is considered to bematuring and in a declining phase. However, thepopulations reached by TOP—FSWs and MSM—bear more of the HIV burden in this concentratedepidemic (National AIDS Programme, UNFPA,UNAIDS and Global Fund Country CoordinatingMechanism 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 NationalStrategic Plan & Operational Plan on HIV and AIDSincludes a focus on sexually transmitted HIV, partic­ PSI/Myanmarularly among people at highest risk. This means ad­dressing HIV vulnerability and transmission amongsex workers and MSM. People who inject drugs(PWID) also suffer a high burden of HIV (National asked why people sell sex, United Nations (UN) andAIDS Programme, UNFPA, UNAIDS and Global nongovernmental organization (NGO) representa­Fund Country Coordinating Mechanism 2011a, tives and sex workers all referred to the economic2011b), and PWID may overlap with sex workers of situation in Burma. A comparison to Thailand, whichall genders and with MSM (FHI 2010). shares Burma’s longest border, offers practical in­ sight into the economic situation: “Someone born inSex between men (though not between women) Thailand can expect to live seven more years, haveis criminalized in Burma, as is sex work. When almost three times as many years of education, and2 aidstar-One | December 2012
  3. 3. aidstar-One | CASE STUDy SERIESsave almost eight times as much as someone born and maternal and child mortality. Improved qualityin Myanmar [Burma]” (UNDP 2009). of life refers to:High unemployment and widespread poverty limit • Increasing access to social support spacethe job options for MSM and uneducated womenwith few skills. Selling sex has low barriers to entry, • Reducing stigma and discriminationbut exposes sex workers to greatly increased riskof HIV and other health problems. The 2008 Behav­ • Enabling a community voice and communityioural Surveillance Survey reported that HIV preva­ advocacylence among FSWs in Burma was 18.4 percent(HIV and AIDS Data Hub for Asia-Pacific 2010), • Improving access to quality health carewith interaction between FSWs and drug users services.(National AIDS Programme Myanmar and WHO2008). The HIV Sentinel Sero-surveillance survey of2011 reported HIV prevalence of 9.4 percent amongFSWs and that prevalence among MSM had de­ “It’s different with TOP. When weclined from 28.8 percent among MSM in 2008 to 7.8 come to TOP, the TOP staff arepercent in 2011 (National AIDS Programme 2012c).1 warm and take care of members.These data about prevalence do not account for Other organizations are not likedeaths. Although it seems that sex workers who this—there is less care and moretake the places of those who leave their métier ordie are practicing safer behaviors, among MSM, it stigma.”appears that safer behaviors have not caught on in — Male sex workerthe same way, and more work to combat the spreadof HIV is necessary. Stigma and infrastructureweaknesses, as well as political conflict in someparts of the country, impede HIV prevention efforts PSI/Myanmar’s research team started with mapping(National AIDS Programme 2010, HIV and AIDS exercises to identify where sex workers and MSMData Hub for Asia-Pacific 2010). congregated. TOP then hired and trained outreach workers and peer educators from among the FSWTOP was started by PSI with support from the U.S. and MSM communities to encourage members ofPresident’s Emergency Plan for AIDS Relief (PEP­ these groups to visit their DICs for health care ser­FAR) through the U.S. Agency for International vices, including reproductive health and HIV-relatedDevelopment (USAID) in 2004, after the Burmese services. Outreach workers and peer educatorsgovernment sought external assistance to address make up the majority of TOP’s 322 staff. It is esti­HIV. TOP’s goal is to improve the health and quality mated that there are 60,000 FSWs in Burma, andof life among FSW and MSM communities in Bur­ TOP reached 47,215 in 2010. It is also estimatedma. PSI/Myanmar and TOP define improved health that there are 240,000 MSM in Burma, and TOPas reduced burden of disease, including HIV, STIs, reached 54,839 in 2010 (TOP, PSI/Myanmar, and1 HIV data among MSM is collected without disaggregating information about male and transgender sex workers. tOp: Scaling up HIV Programming in Burma by Mobilizing Sex Workers 3
  4. 4. aidstar-One | CASE STUDy SERIES USAID 2011); approximately 5 percent of the 54,839 sell sex (TOP and BOX 1. TOP DElIVErS PSI/Myanmar staff 2012). TOP builds on services and strategies to mOrE THAn juST enable FSWs and MSM to lead healthier, more productive lives. These mEDIcAl SErVIcES strategies include delivering more than the minimum package of services for HIV prevention, treatment, care and support. The minimum • Outreach and peer education package typically includes outreach and peer education, voluntary and • DIC safe space confidential HIV counseling and testing (VCCT), targeted media, con­ • Sexual and reproductive dom distribution, STI treatment, materials for safe injecting for PWID, health services including and links to care and treatment (Bessinger et al. 2007). short- and long-term birth control • STI testing and treatment Implementation • On-site laboratory in some TOP offers a range of services to MSM and FSWs within its DICs and locations advocates for sex workers at the local, national, and international level. • VCCT with same-day test TOP reaches out to local authorities, participates in planning national results HIV activities and strategies, and is active in international networks. • Referrals to public and TOP is respected throughout the region; Kay Thi Win, TOP’s Program private providers of treatment Manager for FSWs, was elected to a high-level position representing for HIV-positive people sex workers throughout the Asia Pacific region. • Testing, treatment, and care A critical element of the services at DICs is free medical care: the sex for opportunistic infections workers who visit TOP are primarily low-income sex workers and many and tuberculosis would not seek care for which they had to pay. TOP offers services • Home-based care including beyond HIV and beyond the minimum package of services for HIV (see nutrition for HIV-positive Box 1) because many factors affect a person’s risk and vulnerability to people provided by peers HIV. TOP also works to empower MSM and sex worker communities, • Legal advocacy and an approach that has been linked to greater effectiveness in HIV education programming with sex workers (Shahmanesh et al. 2008). • English language and Each service was developed in response to the situations participants computer classes face. Thus, community members influence decisions about which • Vocational training services to provide and how to implement services. For example, after a participant experienced irregularities upon arrest, TOP engaged an • Lending program attorney to learn about the laws used against sex workers and the • Assistance with identity penalties associated with these statutes. An attorney is sometimes papers, opening bank consulted by TOP staff and participants. The lending program was accounts, and other official conceived of, designed, and is entirely implemented by participants. interactions.4 aidstar-One | December 2012
  5. 5. aidstar-One | CASE STUDy SERIESTOP is now working to be able to offer screeningfor cervical cancer to FSWs because of participantdemand.Input from participants is taken very seriously:when participants said that they do not want to beperceived as targets, but as participants, the nameof the project was changed from Targeted OutreachProject simply to TOP. TOP/PSI/MyanmarDrop-in center–based services: All servicesaside from home-based care are provided at theDIC locations. DICs are intended to be stigma- and FsW field activitydiscrimination-free zones and they offer friendlyservices for these marginalized populations. Whenscaling up in a new location, TOP seeks settings transportation between service providers and dothat offer both shared and separate space. For not need to take additional time away from work toexample, TOP’s DIC in Yangon includes areas visit multiple locations. TOP participants reportedwhere MSM and FSWs can interact, but also sepa­ that more sex workers seek health care morerate buildings where MSM and FSWs can gather in frequently, instead of putting off seeking medicalmore private groups or work on specific campaigns. attention because of financial concerns, nowIn other locations, sometimes the MSM and FSWs that TOP offers free health care for FSWs andgather on separate floors. FSWs and MSM have MSM. TOP is funded primarily by PEPFAR, withfound common ground as well as benefits to being additional funds from the UN; the Global Fund toallied, in addition to the administrative advantages Fight AIDS, Tuberculosis and Malaria; and theconferred by co-location. In general, FSWs face Three Diseases Fund.different issues from MSM—for example, MSMoverall are not a low-income community. TOP and Economic motivations and small loans:PSI estimate that approximately 5 percent of TOP’s TOP staff and participants reported that everyMSM clients are transgender sex workers and male woman engaged in sex work needed to supportsex workers, who—like FSWs—are typically low- herself or her family. Hence the small lendingincome (TOP and PSI/Myanmar staff 2012). Sex program, which helps TOP’s FSW participants getworkers of all genders benefit from sharing space through a crisis without engaging in risky behaviorand working together, sharing information and strat­ in order to get money quickly. For example, when aegies to promote 100 percent access to condoms woman is arrested or has other expenses, she canand personal lubricant. apply for a loan and the application is considered by a committee. Two guarantors are required forDIC health services are provided free of charge and loan approval and repayment is expected within sixin a respectful environment. Multiple services are months. To date, the repayment rate so far is 100available at the DICs, and this has contributed to percent with no defaults since this component ofincreased access and uptake of services because the programs started.participants do not spend extra time and money on tOp: Scaling up HIV Programming in Burma by Mobilizing Sex Workers 5
  6. 6. aidstar-One | CASE STUDy SERIES Social, civic, and educational programs: There is an BOX 2. mAlE SEX impressive level of foresight entailed in thinking ahead about wanting wOrKErS AlSO BEnEfIT to have children, wanting to find other work, and the additional costs frOm TOP of treatment for infections. The importance of this foresight can be difficult to impress upon people working to survive day-to-day, as many Joe, an outreach worker for sex workers are doing. For this reason, TOP offers social programs TOP’s MSM program, meets including education, information, and training which can help sex other TOP and PSI staff at a workers improve their health, their income, and their livelihood. cruising point, near a bridge where men meet other men to DICs hold social activities such as Saturday Clubs for people living hook up for sex. Joe speaks to all with HIV/AIDS (PLHIV) and parties. There is space for relaxing with the people he knows, MSM and peers, allowing time to share information. One participant described especially the men who sell sex, the incorporation of “stealth messages” and information into social who make up about 5 percent of activities, saying, “When we have other emotional issues we have TOP’s MSM clients. funny things and entertainment and we are happy be involved in Joe knows everyone and it is those sessions, and they have messages and information about clear that he is the most popular health and HIV.” man in the cruising area. So though he’s only going a few The Saturday Clubs are more than social events: they are the blocks—a couple of minutes’ forefront of community-based care for PLHIV in Burma, spearheaded walk—Joe arrives 20 minutes by FSW and MSM. Social activities as a form of community-based later. When he arrives, Joe is care are important not only for TOP specifically, because TOP has immediately approached by men a high number of HIV-positive participants and staff, but also around on the bridge who know him and the country who want condoms and personal as additional lubricant to prevent HIV and treatment slots “Before TOP, I knew about STIs. become available condoms and HIV but I did not for HIV-positive use them regularly. Then, from people. The expansion TOP I gained knowledge, and of treatment even if I have regular clients, I use in Burma condoms even with them and with makes these my husband because we know community- that we can get STIs from regular based support systems clients and we need to protect essential for ourselves and treat ourselves adherence to and on time. Otherwise, STIs can understanding of lead to problems when we marry treatment. and want children, so we use TOP also condoms.” provides — Female sex worker education that6 aidstar-One | December 2012
  7. 7. aidstar-One | CASE STUDy SERIEScan increase male, female, and transgender sexworkers’ ability to earn a living. For example, TOPoffers English language and computer instructionon-site at the DICs. The program offers informationand advice about obtaining national identity cards,which enable participants to travel freely throughoutthe country, open bank accounts to save money,and attend school. Participants linked these skillsand information to improved health and careeropportunities. As one FSW explained, “If we save TOP/PSI/Myanmarmoney, then we have money and we can take fewerclients and this is good for our health. If we havea passport and an opportunity for a job in another[HIV program] agency, we can have job options FsW social event dayoutside our country. We need the national identitycard for jobs in the country, too.” involvement in every program activity, includingVocational training for FSWs and MSM is intended deciding what programs to undertake, determiningto provide skills that can allow participants to run how to implement them, and ensuring that hiringa small business, such as selling flowers or being starts in the community. To begin with, TOP isa stylist because, as one participant pointed out, committed to hiring sex workers and MSM in“Many bosses do not want people living with HIV/ professional, paid staff positions. This allowsAIDS or sex workers.” Planning for the future was TOP access to the insider knowledge of its targetanother important aspect of vocational training. community, which is best positioned to identify newOne sex worker explained, “Sex work is not viable needs and emerging problems. It is an approachfor the whole life span; it is not a living for old described by TOP’s Kay Thi Win as “bottom-uppeople. Vocational training will help people continue decision-making with different levels of people andto work.” negotiation.” Programming decisions begin with a consultationTOP’s Strategies among staff and participants. Decisions are made in a consensus process with those affected. StaffTOP’s success builds on multiple elements. In first discuss pending decisions with managementaddition to the comprehensive medical and social and team leaders; if the decision involves or affectsservices described above, the program relies the community, then discussion with peer educatorson specific strategic components. These include and participants follows. Another round ofcommunity involvement in project activities and discussions may follow; the process can be lengthy,planning as well as rigorous data-gathering but the resulting support from and to the communityto capitalize on successes and plan for future is worth the effort.programming. Building community capacity — TOP is committedTOP’s philosophy of community to the “peer progression model,” hiring from theinvolvement: TOP is founded on community FSW and MSM communities. Because of its hiring members of the community, TOP has constituted a tOp: Scaling up HIV Programming in Burma by Mobilizing Sex Workers 7
  8. 8. aidstar-One | CASE STUDy SERIES first step for professional training for many staff members. More BOX 3. TOP’S PEEr than 20 TOP outreach workers and peer educators have moved PrOgrESSIOn mODEl: on to work for other organizations, creating openings for other THE clInIc ASSISTAnT sex workers and MSM to be hired. TOP’s capacity building and training for community members and employees has enabled TOP is committed to hiring sex workers TOP to promote and hire community members for other positions, and MSM in professional, paid staff so that only those positions requiring specific licensing (such positions. While most community as doctors) or very technical skills (such as data analysis or members start as peer educators or bookkeeping) are held by people who are not members of the outreach workers, Sue was hired to community. be the clinic assistant. She sought the position because she wanted to Capacity building is now under way to help community members reduce her vulnerability to arrest. She learn the skills necessary to undertake more of the tasks requiring said, “I worked on the street, and I saw technical knowledge. These hiring and capacity-building practices peer workers and we talked and they ensure that TOP includes FSWs and MSM at all possible levels, gave me IEC [information, education involves the community in decision-making, and makes sure and communication] materials. Then that staff interests align with those of the community. This also I came to TOP and got services but I ensures that there are potential staff people for new locations, did not want to work here. Then I was as expansion to new locations is determined by the needs of sex arrested. I had to stay in the prison, workers and MSM as reported by current participants. and when I came back, I worked and was arrested and went back to prison, Strategic data-gathering to inform planning: To and to the rehabilitation center. When determine what will promote its health agenda and what will be I came back from there, I was afraid relevant for the people who use its services at each site, TOP while working. works with PSI/Myanmar on mapping, clinic, and DIC data; Sue clearly needed work that would population size estimation; and PSI’s unique Tracking Results not leave her vulnerable to arrest. Continually (TRaC) system. Strategic information-gathering helps However, without education and with advocacy, planning, and—importantly—demonstrating the experience, her options were very program’s performance and effectiveness. Data demonstrating limited. TOP understood that it would TOP’s effectiveness, such as the decline in syphilis and HIV have to train any community member among TOP participants, has facilitated the TOP scale-up by hired for this position, which involves showing the Burmese government that the project had achieved handling medical samples and lab concrete results. Also, donors are eager to support evidence- equipment such as the centrifuge. based and proven effective programs like TOP. They interpreted Sue’s situation as offering exceptional motivation and Mapping to identify need — TOP conducts periodic mapping hired her. “I came to TOP regularly exercises to ensure that programs are located where sex workers and when there was an opening, I and MSM can reach them, and to be sure that activities are applied and I got the job. I had a lot expanded to new locations where there is demand for health of training to be the clinic assistant.” services for FSWs and MSM. Now Sue has successfully trained Tracking population — Population size estimates (PSEs) are others in clinical procedures and how also important when starting in a new location because they to use the equipment. help measure the number of people in the target population.8 aidstar-One | December 2012
  9. 9. aidstar-One | CASE STUDy SERIESTOP conducted PSEs of FSWs and MSM in each “hotspots,” including information about respondents’new location. A PSE is not a rigorous study, but a places of origin. The results reflected high mobilityreflection of a given area at the time the estimate among FSWs, including among small townships.was undertaken, and of the dedication and skills of For example, the estimated number of FSWs inthe local investigator and the data collection team. Moulmein [Mawlamyine] township, according to keyIdeally, a PSE should be conducted over a few days respondents, ranged from 1,127 to 1,708 during theto avoid overcounting, though this quick execution 30 days of the exercise (PSI/Myanmar 2011). Thesemakes it difficult to conduct PSEs in some settings, estimated numbers can be used to determine howsuch as large cities with many sex workers and many outreach workers and peer educators mayMSM hotspots. Nevertheless, PSEs are useful tools be needed at this location, and later, if seasonal orfor predicting staffing and logistical needs—for other fluctuations are found—in keeping with theexample, how many outreach workers and peer high mobility documented—staff numbers can beeducators are needed, and how many clinic visits adjusted at the site.and tests for STIs and HIV can be anticipated. Thenstaffing can be fine-tuned according to experience. Data-gathering — TOP collects data on daily clinic and DIC attendees, services sought, and referralsFor instance, PSEs of FSWs were undertaken made, as well as clients contacted daily throughin TOP’s catchment areas in late 2011. Key outreach workers and peer educators; these datainformants in five cities where TOP has a DIC and are analyzed by PSI/Myanmar’s research team.peer outreach activities identified suspected new In addition to clinic and outreach information, Figure 2. HiV preValence (%) aMOng FsW and MsM, 2005–2011 source: national aids programme 2012c tOp: Scaling up HIV Programming in Burma by Mobilizing Sex Workers 9
  10. 10. aidstar-One | CASE STUDy SERIESPSI/Myanmar has developed a series of questions HIV in Burma (National AIDS Program, UNFPA,as part of its TRaC data analysis intended to UNAIDS and Global Fund Country Coordinatingidentify determinants of behavior over time and Mechanism 2011a, 2011b).the factors that influence specific behavior.The analysis found, for example, a statistically Numerous actors have contributed to the decline ofsignificant link between having plans for the future HIV and STI prevalence among MSM and FSWs,and consistent and correct condom use. Among including TOP, which has played a major role in partsurvey participants, both MSM and FSWs, those due to its size and scale as the largest organizationwho believed that HIV infection would undermine working with these populations in Burma. While it istheir goals for the future were much more likely not possible to discern exactly what is attributableto report consistent condom use (Tin Aung 2012). to any single program, it is probable that such aTOP frequently uses the concept of future plans decline has been accomplished at least partlyin its outreach and education materials, including, because of TOP’s. NGOs have more communityfor example, a cost-benefit analysis comparing the access than the government and can reach morebenefits of more money for unprotected sex today members of most-at-risk groups, making NGOs aversus lost working time and medical costs for critical part of the service delivery provision as wellinfections over the longer term. as the data collection scheme for bio-behavioral surveillance in Burma. Indeed, a PSI doctor explained that the National AIDS Program hasTOP and Burma’s used PSI and TOP data since 2006 to report to the Department of Health on STIs, treatment referrals,HIV Epidemic and VCCT. TOP will participate again in the next round of national surveillance, including collectingSyphilis also trended downward from 5.5 percent blood 2008 (TOP, PSI/Myanmar, and USAID 2011)to 3.9 percent among FSWs in 2011 (National Evaluations have praised TOP’s methods. OneAIDS Programme 2012c) and from 14.1 percent such evaluation of HIV prevention programming inin 2008 (TOP, PSI/Myanmar, and USAID 2011) Burma—an evaluation to which TOP contributed—to 2.5 percent among MSM in 2011 (National found several elements that led to successfulAIDS Programme 2012c). Since STIs are programs:epidemiologically linked to HIV transmission, theirdiagnosis and treatment are important elements in • Offering multiple components of the minimumHIV prevention. package at one site contributed to the high intensity of service.While HIV prevalence has declined and theseachievements are substantial, the numbers remain • Working with partner organizations furtherquite high. Furthermore, without data about deaths added opportunities for interactions withand people who leave programs and sex work due outreach workers, peer educators, and otherto illness, it is unclear how much HIV has really service providers, contributing to intensity ofdeclined among FSWs and—especially—among service use.MSM in Burma. Despite declines in prevalence,TOP’s work remains extremely necessary. HIV • Core elements of the minimum package, printprogramming for these key populations remains a media exposure, and interactions with outreachpriority in the National Strategic Plan to address workers were associated with more consistent10 aidstar-One | December 2012
  11. 11. aidstar-One | CASE STUDy SERIES condom use among MSM and FSWs (Bessinger successful approach highlights that the community et al. 2007). 2 perspective should not only be welcomed, but embraced and utilized as the expert perspectiveThese are all components common to the TOP on the situations faced by the groups beingprogram. addressed. Another priority in replicating TOP’s approach is to engage in long-term capacity building as necessary for community membersWhat Worked Well to take on management and decision-making responsibilities. This investment in personnel engenders community members’ sense ofCommunity involvement and ownership: ownership of the program and activities.Community involvement has led to a deep feelingof ownership of TOP, which is the key to theproject’s success. “It’s the community themselves TOP’s specific actions in response to the HIVwho have led the mobilization process which has epidemic in Burma may not be appropriatelargely brought the TOP program to scale and to its everywhere, but TOP’s general approachsuccess today,” said PSI/Myanmar Program Officer consulting and involving community membersCeleste Jennings. can be replicated almost anywhere and with almost any population that exists as an identifiable community. Sex workers have responded well toReaching and mobilizing marginalized people like being approached respectfully for collaboration onsex workers is best accomplished through their matters that affect them. The community membersdirect involvement in prevention programming; can help determine what should be done and canwithout their involvement, HIV programming help administrators and managers learn criticalis inherently limited. TOP involves community information such as where to conduct outreach,members in the most direct way possible—by hiring how many people might seek services, and whatand promoting them, and by building their capacity services are desirable. TOP’s success shows thatto run their own affairs. sex workers add value to programs when they are included not only as “targets” but as paid staff doingCommunity involvement requires commitment work valued by their communities. While consultingto inclusion at every possible level. This can be members of the community you seek to address ischallenging, but offers great rewards. TOP’s always a good start, a community-based approachcommunity-driven approach has facilitated the may not be as successful in places where theprogram’s extensive reach across Burma and group you seek to address is widely dispersed orenhanced its contribution to the impressive very disparate and does not form a cohesive orturnaround of the HIV epidemic in the country. identifiable community; in such cases, community building may be a prerequisite.Replicable, community-driven peerprogression model: TOP’s community-oriented Evidence-based programming: TOP hasmodel is replicable, provided that implementers benefited from PSI/Myanmar’s research expertiseand administrators wholeheartedly believe that in analyzing what works, which TOP has scaledcommunity members bring valuable input. TOP’s up and implemented, for example, focusing on2 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). tOp: Scaling up HIV Programming in Burma by Mobilizing Sex Workers 11
  12. 12. aidstar-One | CASE STUDy SERIES 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 TOP/PSI/Myanmar to be able to discuss MSM and sex worker issues, work with MSM and sex workers, and promote consistent, correct condom use. This sensitizationMsM drop-in center activity took time, but was essential to TOP’s success in addressing HIV and STIs.future goals as a reason to protect oneself andothers from HIV. Furthermore, offering evidence of A doctor with PSI/Myanmar described the changesTOP’s effectiveness is a great asset in discussions that have happened, saying, “I was not good aroundwith the government and donors about ways to MSM but now they are my friends. The point isaddress HIV and how to support these efforts. PSI/ for the organization and local staff, the attitudesMyanmar’s research team assisted TOP in the have changed dramatically over the years.development of methods for mapping and PSE, The female staff, they used to be giggly andand the identification of sound strategies for HIV embarrassed about the demonstrations and howprevention education such as attention to future to use condoms, but now it is routine. Also, MSMplans and demonstrating the need to prevent and FSW are well integrated into the structure.infection if one is a PLHIV. Additionally, PSI/ They are just other staff.”Myanmar’s research team helped develop the datacollection methodology for the clinic and DIC data. Ensuring that TOP facilities offer clients a safe,PSI/Myanmar’s analysis of the data collected by discrimination-free environment has in turnTOP demonstrated the correlation between TOP’s strengthened the trust of TOP’s client communities.activities and the decline in STIs and HIV among Sex workers described not only the acceptance andMSM and FSWs since TOP started delivering friendliness of the health care providers but alsoservices. the quality of both the clinic and social services. As one participant shared, “When we come hereEnvironments free of stigma and from home and we have problems with family anddiscrimination: TOP DICs are intended to money, we are here with our friends and we go tooffer a welcoming, friendly space, free of stigma work. This is a safe space. We can shower andand discrimination, to help create an enabling dress and get ready for work” without being lookedenvironment for HIV prevention programming. down upon.However, it took time, persistence, and closework with staff members to create an accepting Valuing community input and experience — Theenvironment. opinions of community members are highly valued and used in programmatic decisions, including maintaining a friendly and welcoming environment.12 aidstar-One | December 2012
  13. 13. aidstar-One | CASE STUDy SERIESFor example, when a doctor was hired but then workers and peer educators. The proven abilitywas reported by participants as being insufficiently to implement effective programs has enabledfriendly to community members, another doctor was TOP peer educators and outreach workers tohired to work directly with community members. become employees with other programs, creatingWhen possible, members of the community, such job openings for other TOP participants. In thisas doctors who are MSM, have been hired. In this way, TOP addresses a need within the participantexample, the other doctor was reassigned within community in that there is a dearth of professionalPSI but outside TOP. jobs that they can apply for. The peer progression model is one way to help community membersIn some cases, hiring sex workers may require develop skills that may help them get other jobslong-term capacity building. While this can be in the future, as demonstrated by the numbers ofmore resource-intensive at first, it contributes to TOP employees who have moved to employmentcommunity ownership and creates employment with other organizations. Furthermore, thisopportunities for people who might not have many also contributes to the reduction of stigma andjob options. discrimination against sex workers and MSM at other organizations and more broadly.Demonstrating the competence of MSM and sexworkers — The peer progression model also helps However, sex work remains highly stigmatized andto reduce stigma and discrimination beyond TOP sex workers feel this stigma when they interactsites. Sex workers and MSM demonstrate that they with people of higher status; this remains an issuecan learn information, skills, and techniques that when TOP participants are referred elsewhere forthey can use to be highly effective outreach workers services. For this reason, when TOP refers peopleand peer educators, and that they can implement to other agencies, a TOP staff person will oftenprogramming. Their experience as members of go with them. Results are better when TOP staffthe target populations and the interpersonal skills accompany participants to other agencies becausedeveloped both by marginalized populations and the presence of another service provider, the TOPin sex work contribute to their abilities as outreach 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 TOP/PSI/Myanmar 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 peopleannual award for tOp site to work with, sometimes initiating relationships tOp: Scaling up HIV Programming in Burma by Mobilizing Sex Workers 13
  14. 14. aidstar-One | CASE STUDy SERIESwith two or even three individuals before finding right people to manage the tasks currently managedthe right fit. Staying focused on each step requires by PSI/Myanmar or to manage agreementsgreat perseverance, and TOP expressed extreme with PSI/Myanmar in continuing partnership.gratitude to its donors for sticking by the project Nevertheless, questions about how autonomy andduring the difficult, sometimes stalled, process of independence will be maintained remain to bescaling up. answered. TOP staff may require further capacity building in order to manage financial reporting, dataObtaining government buy-in: Donors analysis, and fundraising. TOP plans to continuehave encouraged TOP and its partners, including using the community-based, bottom-up decision-government agencies, to allow TOP to continue making process that has contributed to the highand to scale up its critical public health work with level of participation and ownership by sex workers.key populations, even when those populationsengage in behavior that is against the law. Thegovernment has limited capacity to offer point-of-care HIV-related services, so most services Recommendationsare provided by NGOs and supported with Involve members of the communityinternational donor funding. Because of the strong being addressed in decision-making:data collection and analysis by TOP and PSI/ Key affected populations should be involved inMyanmar demonstrating TOP’s deep reach into the the conceptualization and implementation of anyFSW and MSM communities and ability to deliver HIV-related programming that targets or affectsservices, the government recognizes the public them. Grassroots efforts enabled TOP to reachhealth significance of TOP’s work. The government “unreachable populations” such as FSWs and MSM,has included TOP data in government data since including transgender people and men who sell sex.2006. For example, TOP collects blood samplesfrom FSWs and MSM for bio-behavioral and TOP’s relationships with local authorities, theseroprevalence surveys conducted in Myanmar. National AIDS Program, and the trust of donorsThe government sees TOP as a valued partner combined to afford TOP great autonomy toin these efforts. TOP relies on the government undertake a community-based, grassrootsto support its work—without such buy-in, the approach to HIV programming with sex workersgovernment could simply close TOP. However, and MSM. Autonomy in programming designthis buy-in is promoted by international agencies and implementation enabled TOP to developand included in the National Strategic Plan (NSP). programming solely in consultation with programInternational donor support for this work has made participants from key affected populations anda great difference in TOP’s ability to negotiate its epidemiological and social marketing experts,position within the NSP. rather than in response to an externally imposed agenda.Reaching new levels of organizationalmanagement: This is an exciting but also Involve members of the community inchallenging time for TOP because TOP is set to service provision, especially testing:spin off from its parent organization, PSI/Myanmar, TOP’s staff includes certified technicians whomover the next few years, according to its agreement the government allows to conduct HIV testing. Inwith USAID, TOP’s largest donor. TOP staff addition to the counselor who conducts the testing,manage the DICs, and so it is clear that they will be peer educators accompany community members toable, with training and capacity building, to hire the14 aidstar-One | December 2012
  15. 15. aidstar-One | CASE STUDy SERIESbe tested for HIV at TOP sites and at government- FSW Program Manager Kay Thi Win describedrun clinics. These relationships encourage FSWs TOP’s persistence, explaining that each time TOPand MSM who are at higher risk of HIV than the staff encounter an obstacle, they strategize and trygeneral population but who simultaneously stay to identify three different ways to overcome it. Thisaway from stigmatizing situations, including in can entail long waits to determine what to do, whomhealth services, to seek testing. Testing is important to approach, and how to approach them; give eachbecause it is the gateway to treatment, care, and attempt time to work; and then come up with and trysupport for PLHIV. another strategy. At each new location, successful scale-up required working with new local authoritiesReach out to new sex workers as soon as and business owners and managers—eachpossible: HIV prevalence among young FSWs interaction presenting a possible challenge requiring(aged 15-19) has declined since TOP started, persistence.from over 40 percent in 2005 to 10.4 percent in2011 (National AIDS Programme 2012c). But even In some cases, resolution has taken years. And inwith TOP’s successful outreach to FSWs, 10.4 those cases, TOP was able to envision reasonspercent HIV prevalence among young FSWs (aged to persist and take hope from the possibilities15–19) in Yangon, the largest city, is alarming, and previous triumphs. The key to successfuland is slightly higher than in 2009 and 2010 even persistence is to remain optimistic and focused inas rates of HIV among other age groups declined the face of adversity, while simultaneously making(National AIDS Programme 2012b). This reflects realistic assessments of what to try next.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). Future ProgrammingIn light of this vulnerability at the time of beginningsex work, it is critical to reach the newest entrants TOP has contributed to the success of the struggleto sex work and to promote HIV prevention among against HIV in Burma, but there is more to be done.this group early and often. To do this may require Citing TOP’s services, a male sex worker said, “Weincluding NGOs like TOP but also management and want TOP to be sustained. We have seen otherother sex workers at venues with staff who may be groups come and work and then they leave, and wenew to the trade to promote HIV prevention skills don’t want that to happen to TOP.” Its communityamong new sex workers. management focus contributes to TOP’s potential sustainability, but long-term capacity building orPerseverance is crucial for success: TOP connections to people and organizations that canhas received great accolades, but few people assist with fundraising and data analysis are alsohave heard about the great perseverance required critical to success.during the past eight years in order to scale up theprogram around the nation. One of the lessons TOP’s great accomplishments in difficultTOP offers other projects is to persevere and stay circumstances inspire optimism about what can befocused on meeting the needs of your participants. accomplished not only by TOP but elsewhere. TheThey are the key to the drive needed to push program’s approach of peer outreach, communityforward despite the obstacles that invariably arise. mobilization, and DIC-based services can serve as aTOP has found solutions to each challenge, but not model for other programs. gwithout a high level of determination. tOp: Scaling up HIV Programming in Burma by Mobilizing Sex Workers 15
  16. 16. aidstar-One | CASE STUDy SERIESREFERENCES Operational Plan. Available at http://www. (accessed May 2012)Bessinger, Ruth, Maung Maung Nyein Chan, KimLongfield, Tin Aung, and Habibur Rahman. 2007. National AIDS Programme. March 2012a. GlobalEvidence for a successful implementation of the AIDS Progress Report Myanmar. Available at http://minimum package of HIV prevention interventions (accessed May 2012)in Myanmar. USAID, Measure Evaluation & PSI. National AIDS Programme. Presentation to theAvailable at Sexual Transmission Working Group, Naypidaw,publications/tr-07-60/?searchterm=None (accessed Burma, April 2012b. Slides.May 2012) National AIDS Programme. 2012c. Results of HIVFamily Health International (FHI). 2010. Young Sentinel Sero-surveillance 2011 Myanmar. Yangon:People Most at Risk of HIV: A Meeting Report World Health Organization.and Discussion Paper from the Interagency YouthWorking Group, U.S. Agency for International National AIDS Programme. 2010. UNGASS CountryDevelopment, the Joint United Nations Programme Progress Report, Myanmar. Available at http://www.on HIV/AIDS (UNAIDS) Inter-Agency Task Team on and Young People, and FHI. Research Triangle item/13892-ungass-country-progress-report­Park, NC: FHI, 2010. Available at http://aidsdatahub. myanmar-national-aids-programme-myanmar-2010org/en/reference-librarycols2/hiv-prevention/ (accessed March 2012)item/15895-young-people-most-at-risk-of-hiv­unaids-and-fhi-2010 (accessed May 2012) National AIDS Program and World Health Organization. National Behavioral SurveillanceHIV and AIDS Data Hub for Asia-Pacific (August Survey 2007-2008 Report Myanmar on Injecting2010). Sex Work & HIV Myanmar. Available at http:// Drug Users and Female Sex Workers. World Health Organization. Available at www.myanmar.pdf (accessed May 2012) (accessed May 2012)Kraus, Steve. 2011. “Regional Overview of Progresson Universal Access in Asia-Pacific.” Presentation PSI/Myanmar. “Estimation of FSW population size.”at Getting to Zero, Bangkok, Thailand, March Internal presentation, November 2011. Slides.30–31, 2011. Shahmanesh, M., V. Patel, D. Mabey, and F.National AIDS Program, UNFPA, UNAIDS and Cowan. 2008. Effectiveness of Interventions for theGlobal Fund Country Coordinating Mechanism. Prevention of HIV and Other Sexually Transmitted2011a. Myanmar National Strategic Plan & Infections in Female Sex Workers in Resource PoorOperational Plan on HIV and AIDS 2011- Setting: A Systematic Review. Tropical Medicine2015 Concise Version. Available at http://www. and International Health 13:659– (accessed May 2012) Silverman, Jay G. 2011. Adolescent female sexNational AIDS Program, UNFPA, UNAIDS and workers: invisibility, violence and HIV. Archives ofGlobal Fund Country Coordinating Mechanism. Disease in Childhood 2011;96:478–481. doi:10.1136/2011b. Myanmar National Strategic Plan & adc.2009.178715.Operational Plan on HIV and AIDS 2011-201516 aidstar-One | December 2012
  17. 17. aidstar-One | CASE STUDy SERIESSopheab H., G. Morineau, J. J. Neal, V. Saphonn, RECOMMENDED CITATIONand K. Fylkesnes. 2008. Sustained high prevalenceof sexually transmitted infections among female Ditmore, Melissa, Ph.D. 2012. Targeted Outreachsex workers in Cambodia: high turnover seriously Project (TOP): Scaling up HIV Programming inchallenges the 100% condom use program. Burma by Mobilizing Sex Workers. Case StudyInfectious Diseases 8:167. Series. Arlington, VA. USAID’s AIDS Support and Technical Assistance Resources, AIDSTAR-One,Tin Aung (Director of Research, PSI/Myanmar). Task Order 1.Interview. May 2012.TOP and PSI/Myanmar staff. Interviews. May 2012. Please visit for additional AIDSTAr-One case studies and otherTOP, PSI/Myanmar, and USAID. 2011. “Addressing HIV- and AIDS-related resources.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 andDevelopment. New York: Palgrave Macmillan.Available at (accessed May 2012)ACKNOWLEDGMENTSThe author would like to thank Habib Rahman andTOP staff, clients, and partners for sharing theirstories and experiences with TOP. The authorwould also like to thank PSI/Myanmar staff andrepresentatives of UN agencies and donor agencieswho shared their opinions and experiencesworking with TOP. ThuVan Dinh with USAID/Burma, Cameron Wolf and Clancy Broxton withUSAID/Washington, and Heather Bergmann, HelenCornman, Stephanie Joyce, Repsina Chintalova-Dallas with AIDSTAR-One offered importanteditorial input. tOp: Scaling up HIV Programming in Burma by Mobilizing Sex Workers 17
  18. 18. AIDSTAR-One’s Case Studies provide insight into innovative HIV programs and approaches aroundthe world. These engaging case studies are designed for HIV program planners and implementers,documenting the steps from idea to intervention and from research to practice.Please sign up at to receive notification of HIV-related resources, includingadditional case studies focused on emerging issues in HIV prevention, treatment, testing andcounseling, care and support, gender integration and more.