According to results of HIV sentinel sero-surveillance 2011 in Myanmar, HIV prevalence among MARP continues slow declining direction since 2009. Among MARP, HIV prevalence in Female Sex Worker (FSW) was 4.3% in 1992, rose to 38% in 2000, and then declined to 9.4% in 2011. HIV prevalence was 4.7% in Lashio, 5% in Mandalay, 7.5% in Taungyi, 9% in Myitkyina, 11% in Kyaingtong, and highest in Yangon (18%). Prevalence of Venereal Disease Research Laboratory test (VDRL) positive was highest among FSW and male who have Sexually Transmitted Infection (STI). Comparing VDRL positive rate between urban and rural populations, it was significantly higher in FSW in urban area compare to Intravenous Drug Users (IDU), Men who have Sex with Men (MSM), pregnant women, Tuberculosis (TB) patients, and male who have STI. Prevalence of syphilis was found significantly higher in FSW who have HIV positive (MOH, 2012a).
1.2 Socio-cultural and economic of Myanmar at a glance
Myanmar is made up of 135 national races, multi-society country. Buddhism is major religion, and 89% of population practiced it. Socio-cultural norms are much more influence on women. Inflation is high in Myanmar; year-on-year percent change is 10.7 in 2005 compare to other low income countries in Asia continent. It fluctuated a lot 32.9 in 2007 and down to 8 in 2009 and 7 in 2010, respectively. Out-of- pocket expenditure on health is high (86.9% in 2006). Poverty headcount index is 32% at national level (UNFPA, 2010).
2. Socio-cultural and economic factors that shape HIV/AIDS risks to female sex worker
Like many Asian countries, sex work is not encouraged and illegal in Myanmar. Criminalization of sex work and sex workers involuntarily leads to mistreatment of women with sex work. Most of the FSWs mentioned that they have chosen this type of occupation because of limited job opportunities and options. Economic factors make young women to become sex workers. Socio-cultural and economic factors make a person more likely to engage in risk taking behaviors that eventually incline to HIV infection (UNFPA, 2010).
FSWs are generally regarded as the people who defy the acceptable social norms and behaviors. Not only lack of social status but also afraid of losing the clients, most of the time FSW failed to negotiate safe sex practices with clients. Lack of social or economic status, female sex workers are frequently the victims of gang rape or abusive conditions. FSW used barrier method less with regular or intimate partners due to the fact that their partners might see them as sex workers (Talikowski & Gillieatt, 2005) (UNFPA 2010).
3. Strategies to reduce HIV/AIDS risks
3.1 Brief explanation of response by Health care System to HIV/AIDS
Since 1989, prevention and care activities regarding HIV/AIDS are carried out in Myanmar as one of the disease of national concern with high political commitment. Multi-sectoral National AIDS Committee (NAC) was formed in 1989. Currently, national response to HIV and AIDS was implemented with aim of Three Zeros; Zero New HIV infections, Zero Stigma and Discrimination, and Zero Death. It was guided by Three Ones principle (One HIV/AIDS Action Framework, One National Coordinating Authority, and One monitoring and evaluation system) of National Strategic Plan (NSP) on HIV and AIDS (2011-2015). NSP was developed with inputs from all stakeholders under the guidance of NAC and was monitored according to national monitoring and evaluation plan (MOH, 2012b).
3.2 Strategies to reduce HIV/AIDS risks to Female Sex Workers
(Note: I will focus only on female sex workers among sex workers)
Due to the concentrated nature of epidemic, targeted intervention will mainly focus for FSWs in high priority townships identified by National AIDS Program (NAP) where greatest potential for spread of infection. All strategies and targeted interventions of the project will carry out in line with Three Ones principle of NSP on HIV and AIDS (2011-2015) and Three Zeros aim. Project will perform up to 2015 starting from 2012.
The primary beneficiaries of the project will be FSWs in priority townships. Board goal of the project is to reduce HIV/AIDS risks to FSWs. Following are the specific objectives - reduction of transmission of HIV and vulnerability, particularly among people at highest risk especially FSWs; improvement of quality and prolong life of FSW living with HIV through appropriate treatment, care and support; to increase FSW access to and use of Voluntary Confidential Counseling and Testing (VCCT) services; and mitigation of socio-cultural and economic impacts of the epidemic especially on FSWs.
The purpose of the project is to increase intervention coverage for FSWs (consistent use of condom by FSWs will be over 95% in 2015), more number of FSWs living with HIV or affected by HIV are able to receive support in accordance with assessed needs, protection of human right of women if they are to avoid infection and withstand the impact of HIV, to early detection and treat STI among FSWs, reduce the stigma and discrimination on FSWs in NAP identified priority areas or townships, and promote knowledge and acceptance of HIV/AIDS among institutions such as schools, hospitals, etc and communities.
The central project strategy is subsidised the condom for prevention of transmission of infection, Pre-Package Treatment (PPT) kits for treatment of STI, quality diagnostic test kits for detection, Targeted Outreach Program (TOP) through Interpersonal Communicators (IPC), provide Drop In Centre (DIC), VCCT service centre and referral pathways with partners, and supply products to trained health providers (doctors, primary care providers), International Non-Governmental Organizations (INGOs), local community based organizations (CBOs), and so that they may serve the project's primary beneficiaries. By supplying quality products and services within priority areas identified by the NAP, is important to address the issue of access and availability, one of the most significant constraints related to tackling the burden of HIV/AIDS in FSW in Myanmar. In addition to that, following two activities will carry out concurrently to reduce the HIV/AIDS risks for FSW (1) distributing of high quality assured PPT kits for STI with hologram via largest pharmaceutical distributor with subsidised price to flood the market for urgent replacement monotherapy, with message to seek the diagnosis and treatment of STI from trained health providers (2) distributing of male condoms (with different flavours and colours) and female condoms through pharmaceutical distributor with subsidised price to available everywhere, with message to protect yourself and don't assume cleanliness based on physical appearance.
Social marketing strategy is appropriate for an intervention to reduce HIV/AIDS risks for FSWs in identified areas by NAP.
Target population- Female Sex Workers in high priority townships identified by NAP
Products/Services
Using condom for personal protection against HIV/AIDS, and seeking health care and taking full course of quality assured PPT kits in case of STI (that will be facilitated by distribution of high quality PPT kits with subsidize price to providers, INGO, local CBO, and drug shops which are enhanced by promotional activities).
Using DIC for betterment of health of FSW where prevention of HIV/AIDS programs and activities are taking place by peer, screening and treatment for STI, and HIV testing can carry out by trained health care providers (that will be facilitated by referral pathways between INGO, local CBO, and general practitioners)
Using VCCT centers to get the HIV testing done anonymously and VCCT centers will play a role in reducing stigma and discrimination to FSW who seek HIV status. It also sensitizes the general population perception on HIV/AIDS and plays a role in lessening stigma and discrimination on HIV/AIDS.
Price
Subsidized price for condoms (male and female) and PPT kits for STI (subsidized the price is according to willingness to pay study before the project)
With added values according to products/services, you are able to protect yourself from HIV/AIDS; you can seek quality assured treatment from trained health care providers; you can know your HIV status anonymously.
On the other hand, price is regarded as what other costs or barriers are associated with doing the behavior. For example - Inconsistent use of condom, unconsciousness of breakage of condom which will occur due to lack of knowledge how to wear condom (improper use of condom), unaware of the potential dangers of getting HIV/AIDS from clients, self-medicated practices in treating STI, not seeking care from trained health providers due to inaccessibility (or) stigma and discrimination, unaffordable to appropriate health services /medicines
Place
The context of where the communication may take place may depend upon the products/services which are mentioned above. The places are at hotspots, brothel, hotel, and restaurant, night clubs, DIC, VCCT centers, markets, tea stalls, clinics / hospitals, drug shops, during Night show of traditional folk media, after top 10 songs program of radio channel, local sporting & entertainment events (Local “chin lone†matches or music related events).
Promotion
Integrated communications strategy will be implemented through existing resources with using IEC (information, education, communication) materials such as poster, pamphlets, vouchers by IPC, and distribute to brothels, DIC, VCCT centers, providers' clinics or drug shops, Using traditional folk media, Using billboard and radio channels, Health talks will be provided by providers (doctors / trained health workers) to encourage prevention of STI & HIV/AIDS, prompt diagnosis and treatment of STI, Update treatment guidelines in accordance with National treatment guidelines for STI will give to providers.
Social marketing strategy can provide not only services and products, but also behavior change communication activities to reduce the HIV/AIDS risks for FSWs. During the intervention, it's necessary to strengthen the enabling environment for FSW through advocacy to policy makers to make sure interventions are as effective as possible. Advocacy meeting should be held on legal reform workshop & enforcement of policy regarding possession of condom is not used as liability of sex work.
Concentrated efforts and a high number of activities in a focused area are needed in concentrated epidemic. Reduction of HIV/AIDS risks for FSW can never be able to do by a single intervention because it is a complex issue. But, this can only be achieved by a strong multifaceted approach focusing on long term and short term solutions. For fulfilling reduction of HIV/AIDS risks for FSW, social marketing strategy is the suitable way to get things done with vigorous responses and timely manner through various channels in short term, and also give the way for sustainability compare with other strategy. Lastly, social marketing framework can incorporate into existing infrastructures, and resources with low cost, and it makes diffusion of idea and desired products/services into target groups more efficiently and effectively.
