The [him] moderator is a fan of PSI Myanmar's TOP programme and knows it deserves praise. But there is a problem with a recent publication that highlights the TOP programme. Melissa Ditmore has recently written a monograph on a holistic approach to HIV prevention programming for female sex workers for PEPFAR and USAID. Although the views are her own, the monograph has the logo of the two organisations on it. They look like imprimatures.
There is an error in attributing a possible fall in prevalence among sex workers in the publication. The entire section on the TOP programme is below. But the error is in this section copied from the monograph: "The 2008 Behavioural Surveillance Survey reported that prevalence among FSWs in Myanmar is 18 percent, with overlap among drug users. Despite all of these challenges, TOP’s achievements are impressive. HIV prevalence among FSWs who participate in TOP has declined to 11.2 percent from a high of 33.5 percent in 2006."
Ditmore's statement makes it appear that prevalence is lower in sex workers who attend TOP centres. This is not true. The decrease from 33.5 per cent to 11.2 per cent is in all sex workers included in sentinel surveillance, not just the ones who attend TOP centres.
When one says that achievements are impressive one must be careful not to overestimate achievements or attribute them to the activities of one organisation. Apparent prevalence can 'decline' for one or more of three reasons. 1) One reason is decreased new infections (incidence) in the past. The cause is always multifactorial. 2) Death is a common reason. Failure to start antiretroviral therapy is the cause of this and antiretroviral therapy leads prevalence to increase. 3) Methods used to measure prevalence may differ. Sentinel surveillance can be done differently or sentinel surveillance can be compared to VCT data. Like apples and oranges. The main cause of this is professional confusion.
TOP Centres may have contributed to a possible decline in prevalence in sex workers. But to suggest that the decline in prevalence has occurred and is a sole achievement of the TOP programme verges on dishonesty. Ditmore could have done better.
[him] moderator
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Best Practices in Action: PSI Myanmar’s Targeted Outreach Program
Projects that integrate these approaches have experienced
unparalleled success in lowering HIV risk
among sex workers and their clients, even in difficult
environments. One example is PSI Myanmar’s Targeted
Outreach Program (TOP), a project funded by the U.S.
President’s Emergency Plan for AIDS Relief (PEPFAR)
through the U.S. Agency for International Development
(USAID), founded in 2004 that conducts HIV prevention
programming with FSWs in 19 cities throughout
the country. TOP distributes male and female condoms
and personal lubricant using a peer-focused strategy. The
project also offers health care focusing on sexual and
reproductive health for FSWs.
TOP must contend with an exceptionally difficult
context for HIV prevention. Infrastructure is poor in
Myanmar, and the nation lacks skilled personnel; political
conflict persistently flares up in some parts of the country,
which impedes local HIV prevention efforts (HIV
and AIDS Data Hub for Asia-Pacific 2010). The 2008 Behavioural
Surveillance Survey reported that prevalence
among FSWs in Myanmar is 18 percent, with overlap
among drug users (National AIDS Programme Myanmar
and WHO 2008). Despite all of these challenges, TOP’s
achievements are impressive. HIV prevalence among
FSWs who participate in TOP has declined to 11.2 percent
from a high of 33.5 percent in 2006. Prevalence of
syphilis among FSWs also decreased, from 5.5 percent
in 2008 to 2.3 percent in 2010 (TOP, PSI Myanmar and
USAID 2011).
Improvements on this scale require strong coverage,
repeat contact, and reiteration of HIV prevention messages;
it is impossible to change behavior on a large
scale with single or sporadic contact. Building coverage
gradually since it launched in one city, TOP reached over
three-quarters of the estimated 60,000 FSWs throughout
Myanmar last year. In 2010, TOP made repeated
contact with 47,215 individual sex workers a total of
196,500 times, about quarterly on average (TOP, PSI
Myanmar and USAID 2011).
Comprehensive, Inclusive Programming that
Addresses Structural Drivers of HIV
TOP achieved such success because it recognizes that
the risks and vulnerabilities of FSWs to HIV are not
related solely to sexual activity but also to social drivers
(Auerbach et al. 2009), including how communities treat
them. To address these drivers, TOP uses a cross-cutting
approach to policy on stigma and discrimination and
community mobilization for sustained positive effects
on health. TOP advocates for policies promoting the use
of condoms by, for example, discouraging police harassment
of people who carry condoms, and by expanding
access to condoms. In addition to addressing social
drivers of HIV, TOP provides a wide variety of direct
services.
TOP’s integrated strategic approach to HIV prevention
offers clinical services, including follow-up counseling,
voluntary and confidential counseling and testing, treatment
for tuberculosis, reproductive health services, STI
treatment and control, and antiretroviral therapy for HIV
infection. Peer outreach activities include education and
communication, materials distribution, and community
building. Peer outreach workers also invite potential
clients to TOP’s drop-in centers, which offer a place
for community building, peer support groups, training
and educational activities, entertainment, and self-care,
including bathing and sleeping. These centers are vital to
TOP’s program; in the first few months of 2011, 43,320
FSWs registered to participate in center-based activities
(TOP, PSI Myanmar and USAID 2011). TOP also provides
services for people who are HIV-positive, including
a buddies program, and sponsors Myanmar’s national
network of HIV-positive people.
An important aspect of TOP’s programming is training
for its health care providers, including efforts to combat
stigmatization, as judgmental attitudes on the part of
providers can alienate sex workers and drive them away
from health care and other essential services (Goodyear
and Cusick 2007; Lui et al. 2011; Sanders 2007).
TOP’s success is in part a result of the high level of
coverage and quality of services offered. But these depend
on the organization’s understanding of the larger
context of the lives of FSWs and situations in society
beyond their sexual activity, which is achieved by including
FSWs in both the design and implementation of
programming. One way TOP does this is by hiring FSWs
as staff, allowing these women to bring their experiences
and contacts to inform programming decisions
and build clientele.
There are other advantages to having FSWs on staff.
Some women who sell sex do so covertly (Hoefinger
2011; van Blerk 2011) to avoid abuse and discrimination.
They may be difficult to identify or contact, but they
need the same HIV prevention materials and services as
other FSWs. Staff who are or have been FSWs are the
people best placed to reach such hidden populations.
http://www.aidstar-one.com/focus_areas/prevention/resources/spotlight_on_prevention/
