Transcribed from a WHO paper document labelled SEA-AIDS 167 Restricted
distributed at the Toronto IAC in August 2006

Summary Note
Review of the Myanmar National AIDS Programme
27 March – 07 April 2006

1. Introduction
      Myanmar is one of the countries hardest hit by the HIV epidemic in Asia. In 2004, a workshop organized by the National AIDS Programme (NAP) with support from WHO and UNAIDS estimated that 338 911 adults (between 15 and 49 years of age) were living with HIV. The figure falls within the range of 170 000 to 620 000 HIV infected adults and children in Myanmar estimated by WHO and UNAIDS for the same year. The NAP with support from WHO and the participation of UNAIDS and UNICEF conducted an external review of the national health response to HIV/AIDS from 27 March to 7 April 2006 as part of the process of development of the National Strategic Plan 2006-2010.

2. Objectives of the Review
      The general objectives of the review were to assess the progress of the national HIV/AIDS programme, especially in areas related to health sector responses, and recommend revision of interventions and strategies. The specific objectives were to review relevancy and adequacy of the National Strategic Plan and existing policies related to health sector responses to HIV/AIDS; assess progress and efficiency of AIDS prevention, care and treatment activities; identify constraints in programme implementation; and, provide recommendations for future plans and the way forward for programme planning, implementation and collaboration among partners.

3. Methods
    Members of the review team were deployed to seven zones and visited eight states and divisions and 23 townships. In these locations, the members had meetings with 20 AIDS committees and 19 AIDS/STD teams. They also visited 24 hospitals, 13 blood transfusion facilities, 13 programmes for the prevention of mother-to-child HIV transmission (PMTCT), six projects on harm reduction for injecting drugs-users and six youth HIV prevention projects, 17 project sites for the 100% Targeted Condom Promotion Programme, seven sex workers’ sites, 12 groups of people living with HIV, nine non-governmental organization (NGO) sites and urban as well as rural communities. Several opportunities were created for NGOs (both national and international) and non-health sectors to provide inputs. At a consultative meeting held at the outset, the team presented the reviews objectives and methodology to about 20 representatives of national ad international NGOs and staff of the Ministry of Health and other ministries. During field visits, the review team held scheduled as well as adhoc meetings with NGOs.

4. Summary Findings and Recommendations
    A general finding of the review was that significant progress has been achieved in the health sector in Myanmar by the national response to HIV/AIDS. The magnitude of the epidemic had been recognized and the efforts needed to respond to it were reflected in formal policy and planning documents. Importantly, there is a stated commitment in existing strategic documents to focus prevention, care and support efforts to the most vulnerable populations. The NAP has played a critical role in the implementation of HIV/AIDS activities through the formal health system, and coordinated the inputs of national and international organizations engaged in this field. The level of awareness among implementing personnel in peripheral facilities and outreach programmes regarding HIV/AIDS prevention, care and support, and the best practices, generally meets the requirements for the performance of their technical role. Management training will add precious skills to this knowledge base. Tools and technical guidelines have also been produced for a broad range of programme components which now require incorporation into structured training materials and curricula.
    These accomplishments deserve recognition. But much work is still needed for the NAP to achieve the greatest possible impact. This can be done through improved management, more efficient use of available resources and mobilization of additional human and financial resources as well as strengthened partnerships.
    In March 2006 the NAP, using a broad-based consultative mechanism, began the formulation of a National HIV/AIDS Strategy for 2006-2010, with invited participation from national and international NGOs and multilateral agencies. The review team commends the NAP for its commitment to develop a broad-based, multisectoral strategy in collaboration with all stakeholders, including people living with HIV.

4.1 Surveillance and Monitoring
    The HIV surveillance system established in 1992 gradually expanded as a sentinel surveillance system to which a behavioural surveillance element was added in 2003. It has produced valuable data which are used centrally for the monitoring, targeting and planning of programme activities. There is a structured management monitoring system in place which produces timely information, although this information could be more effective if focused more on outcome (behaviour change and use of services) than on output (implementation of services and dissemination of materials and commodities) and thereby more appropriately utilized at the local level. The survey team recommended that several aspects of the surveillance and monitoring systems should be further strengthened.
These include:
• The HIV surveillance system should be updated to incorporate new elements, including new surveillance groups, increase coverage and allow comparison over time;
• AIDS case reporting should move towards an anonymous coding system with a single identifier in order to protect confidentiality;
• Procedures for flow of data from implementers to the NAP should be more clearly defined. The reporting mechanism to and from the AIDS committees, township medical officers and AIDS/STD teams should be streamlined, and
• Programme-related information, including surveillance data should be analyzed systematically and disseminated promptly among stakeholders, especially at the local level. All partners should be encouraged to contribute to a standardized management information system.

4.2 Structures and Services

      The NAP provides the leadership in the national response to HIV/AIDS within the health sector and plays a key coordinating role across non-health sectors. This includes formulation of policy, strategies and monitoring of the response. The NAP operational branches comprise a network of 43 AIDS/STD teams in charge of implementing the NAPs public health strategies as well as delivery of certain services, such as Voluntary Confidential Counselling and Testing (VCCT), promotion of use of condoms, management of sexually transmitted infections (STI) and some basic HIV care. The AIDS/STD teams, however, lack sufficient resources to also provide support to neighbouring areas without such teams. Other sectors such as NGOs are also very active in providing such services, particularly to more vulnerable and hard-to-reach populations. The private-for-profit sector is also providing clinical care and HIV testing. The infrastructure of the public health sector has been weakened as a consequence of being chronically under-resourced. Encouraging initiatives have been undertaken to streamline HIV/AIDS along with other health programmes though some of these need to go beyond major urban areas or pilot projects to achieve greater coverage and effectiveness.
      The following recommendations should be implemented for attaining better service results:
• New AIDS/STD teams should be established for each identified priority area and human and financial resources for each increased to meet local needs for prevention and care programmes
• Division of responsibility for clinical care and public interventions is not clearly outlined at the AIDS/STD team level. Team structures, functions and skills need to be reviewed and better referral systems for services with other health structures and service delivery sectors should be promoted.
• The role of AIDS/STD teams should shift from its current emphasis on care and prevention to a managerial, coordinating and supporting one, thereby expanding their outreach and impact through collaboration with national and international NGOs, the private sector and other governmental sectors.
• The private-for-profit sector should be more actively coordinated with and supervised by the Ministry of Health. This is critical in order to ensure quality of services provided by the sector, particularly in the area of HIV testing and HIV/AIDS care.

4.3 Human Resources

    Each other 43 AIDS/STD teams deployed in the country consists of three to 15 staff including a medical doctor (team leader), nurses, investigator/outreach workers, laboratory technicians and support staff. There is, however, a severe shortage of staff to implement HIV programme activities, particularly at the township level. This includes both AIDS/STD teams and available staff in the public health care facilities. Given the prospect of continuing expansion of the HIV programme activities, availability of human resources is and will increasingly become a major constraint. Available skills are also often inadequate on the managerial and programme planning front.
    The following observations are relevant for better and optimum utilization of human resources:
• Adequate human resources need to be mobilized to support the ongoing programme expansion. This includes expanding the number of AIDS/STD teams to cover all priority districts, the redeployment of staff within public health care facilities and modification of roles and responsibilities for optimal use of available resources.
• Implementation and coordination of the national health sector’s response to HIV/AIDS should be strengthened and improved through sustained training of AIDS/STD teams in programme planning, management, monitoring and reporting.

4.4 Financial Resources

    Financial resources available to the NAP from both national and international sources have grown significantly in recent years. However, they are still considered insufficient leaving the health system under-resourced, given the fact that health system under-resourced, given the fact that Myanmar is a donor-constrained country. The recent decision of the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM) to withdraw its support has also aggravated the situation. This abrupt withdrawal has resulted in further delays in the rolling-out of HIV/AIDS care and prevention programmes. The quantum and flow of resources to and from governmental, nongovernmental and external funding sources and the allocation of resources across the implementing entities, programme activities and regions were insufficiently documented for the team to form an opinion about the current financial situation and make forecasts or ascertain the gaps. This information is needed to assess the adequacy of funding in relation to programme priorities.
    Observations made during the review undeniably support the view that the programme is largely under-funded. A donor scheme is being studied to mobilize additional resources in support of activities targeted at three diseases: HIV/AIDS, tuberculosis and malaria (the "3 Disease Initiative", known as 3D). It was also reported to the review team that some difficulties exist in the disbursement and expending mechanisms linked to the grant allocated to the NAP through the Fund for HIV/AIDS in Myanmar. Several internal and external factors were responsible for the initial delays in implementation. The disbursement of funds from the NAP to the AIDS/STD teams is often directly linked to specific projects and not to programmes, thus necessitating individual project funding reports which substantially increase paperwork.
    The review team observed that:
• Public allocation for HIV/AIDS as well as for health in general should be significantly increased in Myanmar is to narrow the growing gap between increasing needs and effective response to them.
• In-depth analysis of funding sources, mechanisms and flow supporting the national response from governmental, international and other sources should be conducted. The availability of this information will enable an assessment of the adequacy of funding for priority areas of the response and the expenditures by different stakeholders, including NAP.
• All stakeholders should contribute to making the "3 Disease Initiative" an effective, sustainable and transparent external financing mechanism.

4.5 Coordination and Partnerships

    Coordinating structures are functioning with regularity in many states, divisions and townships. AIDS/STD teams are playing a key role in leading and coordinating HIV work in their areas of assignment. The local AIDS committees are perceived as a good forum for local advocacy and multisectoral commitment to HIV/AIDS programmes. However, due to the lack of local strategic information about HIV/AIDS, the AIDS committees remain a consultative and advocacy unit rather than a forum for adapting national strategies to the local context. There is a lack of formal mechanisms of coordination with the international NGO sectors at the state/division and township levels, thus missing out on the opportunity of development of critical partnerships at the local level. Similarly, people living with HIV/AIDS do not participate in coordination structures.
    Recommendations for improving coordination between units and sectors include the following:
• Local AIDS committees should serve as a forum to adapt national policies and programmes to the specific local HIV/AIDS context. Their role should evolve from being purely consultative to becoming more action-oriented.
• Regular coordination meetings between the AIDS/STD teams and national and international NGOs and the private-for-profit sector should be formalized. These meetings would create opportunities for the sharing of programme information.

4.6 Supplies and Logistics
    
    The supply of health products in Myanmar works as a centralized "push" system. All products first arrive at the central level in Yangon and are then dispatched to the health facilities through various distribution systems. Health products for the NAP and the AIDS/STD teams, are first stored at the Central Medical Store Department (CMSD) depot in Yangon and then sent to the Central AIDS/STD team store in Yangon General Hospital where shipments are prepared for AIDS/STD teams all over the country. During shortages the health facilities are likely to use their funds to purchase from the local market products that are not always of good quality and have not been approved the Food and Drug Administration Department in Myanmar. However, for the purpose of proper cold storage, the test kits for HIV (blood safety, PMTCT and VCCT) are kept in the National Health Laboratory (NHL). Though the central level maintains detailed records of all allocations made, it does not possess any information on usage and the balance of stocks at peripheral levels since reporting channels are weak. The AIDS/STD teams and health facilities which have to come to Yangon to collect their share of allocated health products lack of adequate transportation means including the ability to maintain cold chain. The budgetary allocation for this purpose is also inadequate.
    It is essential to ensure that:
• The Department of Health allocate a sufficient budgetary provision and/or means of transportation to the state/division AIDS/STD teams and townships for health products. Coordination should also be improved at all levels to rationalize travel to the central level.
• The NAP should as soon as possible start the process of converting the procurement process from a "push" to a "pull" system. This includes training at the peripheral level on stock management, reporting on stock levels and calculation of needs and implementation of buffer stocks at intermediate levels.
• Increased and improved capacity of the Food and Drugs Administration Department for better control over the quality of health products entering the country, including antiretroviral and other expensive medicines.

4.7 Laboratory

    There is a good collaboration and coordination between the NAP and the NHL on laboratory issues. The laboratories visited had adequate staff capacity but often lacked consumables, equipment and other basic infrastructure such as even electricity supply. This undermines, among other things, their ability to ensure proper storage of materials in good cold-chain conditions. The NHL organizes regular training sessions and distributes HIV test kits for use in the network of public health laboratories. The NHL in collaboration with the NAP also organizes regular external quality control on HIV serology covering most of its network of laboratories. HIV testing strategies currently being finalized by the NHL/NAP are in line with recommended best practices. Access to CD4 technology is still problematic even for the small number of existing sites providing antiretroviral therapy. (ART)

    It is therefore recommended that:
• Laboratory operation in sites providing HIV care should be strengthened on the basis of the needs of each site. Particular attention should be paid to reagent and power supply, instrument maintenance and staffing.
• A coordinated national CD4 testing programme with a large geographical coverage area should be established with standardized instruments, procedures, maintenance, technical support, reagent supply and quality assurance. The relative benefits of centralized and decentralized approaches should be assessed. CD4 testing facilities operated by the private sector and NGOs should be progressively incorporated into national CD4 quality assurance systems as these become available.

4.8 Living with HIV
    Activities aimed at ensuring the greater involvement of people with HIV in HIV/AIDS-related decisions and programmes have gained momentum and generated a rising demand for the greater participation of this section of the population in related developments. The review team observed and heard reports that people living with HIV are becoming more visible in different activities. People living with HIV also expressed their desire to be more involved in the process of prevention and care. At the same time, fear of disclosure is still a vital issue for many living with HIV, including those who are already in support groups. Stigma, discrimination and a lack of understanding of their potential contribution to prevention and care are key factors limiting their involvement. Support, compassion, acceptance and understanding are what they offer to others and what, according to them, they seek themselves. People living with HIV also need greater access to services, especially VCCT and ART. They can make a significant contribution to prevention and care through increased involvement in related activities and decision-making. Furthermore, HIV support groups can be more effective with a more participative structure.
    In this regard, the review team felt it pertinent to make the following observations:
• Increased access is needed to services, including treatment for opportunistic infections (OIs), ART and VCCT for those who want to know their status. This is likely to increase the visibility and involvement of people living with HIV as it cuts across care, treatment and VCCT.
• People loving with HIV would make a significant contribution to its prevention and care through increased involvement in activities and decision-making.
• HIV support groups would be more effective with a stronger and more participatory structure.
• A practical framework should be developed for the establishment of support groups that meet the needs of people living with HIV and coordination linking to a national network. This can be achieved by the NAP, NGOs and International NGOs (INGO) collectively.
• NAP and other NGOs/INGOs should give due importance to and allocate separate funds for positive prevention.

4.9 Prevention
    Generally, there has been and incremental increase in prevention efforts, especially relating to injecting drug use and targeted condom promotion for sex workers and their clients. These and other prevention efforts are further discussed here. However, despite Myanmar’s great diversity in terms of the HIV situation and local conditions and resources, the national response remains somewhat uniform and insufficiently sensitive to local specificities. This results from a nationally driven project-based approach, lack of responsive strategic framework and operational plans, scarcity of local community-based organizations and initiatives and the low level of participation of concerned communities, people living with HIV in particular.
    With a view to overcome this,
• The NAP should coordinate operational research and enhance documentation to inform programme planning, priority setting and implementation.
• The AIDS/STD teams and township medical officers should lead in the development of an annual operational plan together with all prevention and care stakeholders. The operational plan should outline accountabilities, responsibilities, targets and coverage. It should be reviewed on a regular basis.

4.10 Sex Workers and their Clients
    Based on NAP records, the 100% Targeted  Condom Promotion (TCP) programme has expanded from four sites in 2001 to 154 sites today. The main activities include, advocacy, training of township staff, formation of condom core groups, geo-social mapping, condom distribution and programme monitoring. The programme was reportedly implemented in most townships visited by the review teams, although for scheduling reasons few teams were able to observe the programme activities.
    The review team recommended that:
• The recommendations of the 100% TCP review in July 2005, as described in the review report, are endorsed by the review team. The NAP should make every effort to implement and monitor these recommendations.
• The NAP should advocate and support nationwide implementation of the programme. Efforts should be made to ensure that the programme covers all direct and indirect sex work, including entertainment establishments.
• Provision of comprehensive HIV/AIDS/STI services to sex workers and clients by NGOs and grass-roots level organizations has increased accessibility to these services. There is a need to further increase the number and reach of quality AIDS/STI services, The NAP should take the lead in promoting the engagement of other sectors (NGOs, general practitioners and pharmacists) in order to reach these services to where they are needed most.
• Self-help groups among sex workers are effective means to build awareness on HIV/AIDS and empower sex workers in the area of HIV prevention and AIDS/STI care. The establishment of these groups should be advocated and supported.

4.11 Injecting Drug Use
    Various elements of the harm reduction strategy have been implemented to some extent in several regions, placing Myanmar among the leading countries in the Region in this programme area. These projects now need to be monitored. Documentation of their effectiveness will help to further strengthen and expand them – in collaboration with the ministries and departments involved – to other parts of the country. These activities include health education on safer injection and sex, outreach, needle and syringe programmes (UNAIDS estimates that in 2005 more than 1,000,000 needles/syringes were distributed with a return rate of 80%) and drug dependence treatment, particularly the recent pilot project in four township with methadone maintenance therapy. Also, although to a lesser extent, income generation and social/recreational activities at drop-in centres, increased condom distribution, peer education, information, education and communication (IEC) services, and referral to a range of organizations have been reported in some townships.
    Some NGOs and INGOs reported that the environment for work on harm reduction has improved in the last year due to closer collaboration with the police in some townships, and that the possession of syringes (or condoms) is no longer a cause of arrest or harassment. Others, however, have reported that arrest and harassment are still a feature of the environment. There was tolerance on the part of the governmental authorities towards needle and syringe programmes but there had been breaches to this approach reportedly at the initiative of individual officers.
    Recommendations for improving coordination between sectors and departments include the following:
• The Ministry of Health, particular the NAP, need to become more involved in support of harm reduction interventions in collaboration and coordination with various stakeholders, including the Ministry of Home Affairs (Central Committee for Drug Abuse Control – CCDAC) and the departments of Law Enforcement and Criminal Justice to guide the development of a joint operational framework which outlines geographical coverage and division of labour between stakeholders.
• The NAP needs to ensure a comprehensive package of harm reduction interventions, including outreach, health education, needle and syringe programmes and drug treatment (in particular, the methadone maintenance therapy), vocational training and income generation and access to ART.

4.12 Men having Sex with Men
    Review team members reported that targeted interventions for HIV prevention with men having sex with men were either non-existent or when undertaken, not of a frequency, quality and scale to produce significant impact.
    The review team observed this:
• The NAP should include the category of men having sex with men in the national surveillance system. This needs to be supported by other strategic information and proper advocacy and programming.
• Existing community peer-based programmes focusing on men having sex with men should be expanded in collaboration with NGOs.

4.13 Uniformed Services
    The review team held several meetings with senior military and police health officers to discuss HIV prevention and care activities aimed at uniformed personnel and their contribution to prevention and care strategies targeted at populations with who they were in contact. There was generally considerable awareness among authorities concerned in proven strategies to address HIV transmission in the context of sex work, injecting drug use and men having sex with man.
    The review teams recommendations include:
• The NAP should support the development and implementation of a national peer education programme, that focuses on behaviour change, within the military and police force.
• The NAP should facilitate access to technical assistance by staff of the uniformed services to expand VCCT, STI treatment, access to condoms, Opportunistic Infection (OI) and ART treatment services and follow-up.

4.14 Institutionalized Populations
    It is well documented internationally that prison populations are at high risk of HIV infection and transmission through injecting drug use and high-risk sexual practices. In the absence of adequate prevention measures, the likelihood of significant numbers of inmates getting infected with HIV is high. This also increases the risk of further spread of HIV to those communities where the inmates return upon their release.
    It was reported that some district AIDS/STD teams do visit prisons to impart health education, conduct diagnosis of sexually transmitted infections and provide treatment to inmates and members of the staff, but there was little information to substantiate the nature or extent of prevention and care activity in prisons.
    It is, therefore, recommended:
• The Ministry of Health should advocate with and support the Home Ministry to build better understanding and reduce barriers to prevention efforts in closed settings.
• The NAP should facilitate the role of prison authorities (especially medical services) towards introducing and expanding implementation of HIV/STI prevention education, services and commodities among prison inmates and staff.

4.15 Young People
    The review team noted that the national life skills programme (life skills-based HIV and substance use education for students of the age of 10 years and above) was well integrated into the core curriculum. Primary and secondary schooling remain a good opportunity to reach out to a large number of potentially vulnerable young people. The consistency of application across grades (primary, secondary and higher levels), and quality, coverage and impact of the programme will require further review and assessment.
    It is therefore, recommended that:
• The NAP should reinforce its collaboration with the Ministry of Education and NGOs to ensure quality and expand coverage of the in school life skills-based HIV and substance use programme.
• The NAP should reinforce collaboration and coordination with various stakeholders – including the Ministry of Education, the AIDS/STD team and NGOs – to guide the development of local joint operational frameworks to reach out-of-school youth (particularly 15-22-year-olds) with behaviour change programmes and relevant services to improve access and coverage.

4.16 Women of Reproductive Age
    The Essential Reproductive Health Programme and, to a lesser extent, the Comprehensive Reproductive Health Programme are vehicles for the campaign against HIV/AIDS. The estimated number of women of reproductive age who are HIV infected has declined, from 118 570 in 2001 to 101 950 in 2005. This is the out of a total population of 13.5 million women of reproductive age in Myanmar. Essential Reproductive Health includes Adolescent Reproductive Health (ARH) in addition to a number of antenatal and postnatal components. ARH started with health education and now incorporates counselling and behaviour change communications and life skills for males and females aged 15 to 24 in townships under a Department of Health and UNFPA supported project. Some review team members were informed of youth information corners attached to the rural health centre service outlets at the township level in 22 of the 100 townships. All concerned with this programme deliberated on the challenges ahead in expanding the reach of youth clinics in terms of finding suitable locations, adequate space and sufficient resources. Youth clinics have not yet  been established within the purview of this programme.
    It is recommended that:
• The NAP should coordinate systematic integration into the MCH and family planning services at the township and station hospital level and in rural health centres of a defined package of HIV prevention (VCCT, STI, counselling and information and condoms).

4.17 Mobile Populations
    Mobile populations are a critically important group with high vulnerability and risk behaviour. Large and increasing numbers of young people and families from Myanmar, especially from the many border areas, migrate to work in various industries in the interior and to other countries including China, Bangladesh and Thailand. Men tend to work in the fishing industry, rubber plantations, ruby, gold and jade mines, transport (as truck and bus drivers) and construction sites. Smaller numbers of women work in agricultural processing plants and shops. Concern over high levels of HIV transmission among these populations is based on the reported occurrence of high-risk behaviours, including sex work and injecting drug use. Trafficking of women for the flesh trade industry has also been reported in some areas.
    There are some good examples of successful initiatives to facilitate access by these populations to effective prevention. The interventions specifically addressing these populations include health education and prevention, special awareness programmes, distribution of leaflets and condoms, STI treatment, VCCT – mainly by AIDS/STD Teams and NGOs (and for the transport sector by the Ministry of Transport) and, in some cases, needle and syringe programmes – and the provision of ART and OI treatment by international NGOs.
    Access to information and services by these populations – by women in particular – is problematic in view of the geography of the various areas – difficulty to access some communities (sex workers, IDUs, etc. ) multiplicity of local languages and dialects and low levels of literacy.
    It is, there, important that:
• The NAP is resourced to coordinate rapid assessments of local patterns of mobility and related vulnerability and risk behaviours of the population and convene stakeholders at the township level and between townships, states and divisions.
• The NAP play a lead role in developing local operational plans which address the information and service needs of priority populations.

4.18 Blood Safety
    The blood safety programme – which includes donor selection, donor deferral, and HIV screening of blood donations – has made good progress in many areas. Screening procedures include universal (100%) testing of either replacement donors (in hospitals at township level) or blood donations (in hospitals at state level). HIV testing is conducted in hospitals with the supply of test kits from the NAP through the NHL. It was reported to the team that 95.19% of the overall blood units transfused in 2004 (191 120 units) had been screened for HIV. One major obstacle to strengthening blood safety is the current lack of infrastructure capacity. Many laboratories at the state/division and township level are unable to stock blood units in proper cold-chain conditions due to inadequate supply of electricity and lack of appropriate equipment. The NHL addressed all these issues in a proposal prepared in 2005 that aimed at strengthening blood services in the country. This comprehensive proposal, which requires funding, has strategies that are in line with international best practices.
    The review team recommended that:
• To improve the safety of blood transfusion services, the Ministry of Health should rigorously enforce policy to prohibit paid blood donations in conjunction with the promotion of voluntary blood donations.
• Township hospitals, in collaboration with the Myanmar Red Cross Society should continue their efforts to reduce dependence on replacement donors by increasing voluntary contribution and donor deferral and ensure that all blood donations and blood products are screened for HIV. The timely, efficient and quality supply of sufficient HIV test-kits is essential.
• Funding should be sought to support the implementation of the NHL developed proposal on strengthening blood services in the country.

4.19 Voluntary Confidential Counselling and Testing
    The number and quality of VCCT services (available in 43 AIDS/STD clinics across the country) has increased in recent years with the establishment of counselling facilities and staff training, particularly through the national PMTCT programme. Nevertheless, the degree of availability of this service to the general public of most-at-risk populations remains extremely limited. Key barriers to better uptake of HIV counselling and testing, as highlighted by many AIDS/STD teams and other stakeholders, include the fear of stigma and discrimination associated with attending AIDS/STD clinics and being identified as a person living with HIV, the limited number of VCCT services, lack of adequate financial support for transportation to these services, issues related to consent and confidentiality and improper HIV test-kit supply management.
    The review team observed that:
• Clear policy guidance from the central level is needed to ensure that all health staff understand the importance of consent and confidentiality with regard to HIV testing. Routine/mandatory testing of any targeted population group should be discontinued.
• Access to both client-initiated and health provider-initiated VCCT should be expanded through the opening of health centre/sub-centre VCCT to the general public, establishment of hospital VCCT teams including “drop-in” access for the public, routine offer of VCCT for TB patients, increasing the number of AIDS/STD teams, expanding the number of approved private, not-for-profit VCCT services and establishing outreach VCCT for most-at-risk populations.
4.20 Prevention of Mother-to-Child Transmission of HIV
    In recent years a standardized and successful PMTCT programme has been developed in the form of a package of activities providing VCCT, prevention counselling and preventive use of a single dose of antiretroviral medicine (nevirapine) that has been implemented in an increasing number of townships. The health centre-based programme began in 2000 and hospital-based services were added in 2004. The programme has been expanding at the rate of about 5-10 townships per year and will soon cover 79 townships, of which 17 include hospital-based services. The PMTCT programme is the major access point for VCCT. Of an estimated 1.3 million pregnant women had been counselled and tested by the end of 2005.
    However, with the emphasis on preventing mother-to-child transmission much more work is required in primary prevention among pregnant women and their male partners and in the follow-up when women and children test HIV-positive.
    Recommendations by the review team included:
• The NAP should conduct an evaluation of the optimal approach for improving the sustainability of the PMTCT programme. Strategies such as integration into other existing health care systems without undermining programme efficiency should be explored.
• At the local level more efficient programme management is needed to minimize the workload of primary health care staff, particularly of sub-centre midwives.
• Increased attention should be paid to primary prevention activities particularly universal provision of post-test counselling and increased couple counselling – and to the referral of woman for HIV care at the time of HIV diagnosis.

4.21 Universal Precautions and Post-exposure Prophylaxis
    Training of the public health staff in universal precautions began in 1994 and awareness of the key concepts is now widespread. Supply of health products necessary for universal precautions was reported to be sufficient though this relied on funds from hospital cost-sharing schemes for local purchase. In some sites it was clear that despite awareness and available means for the protection, the fear of HIV infection persists due to poor understanding of the risk of transmission contributing to the stigma in health care settings. Post-exposure prophylaxis (PEP) kits were widely available but not fully utilized.
    The following should, therefore, be stressed:
• Practical instructions for universal precautions and PEP protocols taking into account local realities should be developed.
• Additional training on PEP for one to two members of the medical staff of each hospital should be organized. Local protocols should be used for refresher training of health staff by a senior member (‘opinion leader’) of each hospital, with particular attention paid to the real risks of HIV transmission.

4.22 Care, Support and Treatment Policies
    Overall, care, support and treatment have gradually found their place in the national strategy. Substantial progress has been made in introducing comprehensive care in government health services, including antiretroviral therapy. This progress, as well as the contribution of international and national NGOs to this effort, and the increased involvement of informal networks of people with HIV augur well for further expanded access to quality care, treatment and support are discussed in further sections of this document.
    From an overall policy and programme perspective the review team recommended the following measures:
• As current plans for gradually increasing access to HIV care including ART are implemented, preparations for large-scale access should be vigorously pursued. The development of a supportive policy environment and expanded national and international financial support should be given particular importance.
• The development of a clear National Continuum of Care Policy and operational model is an urgent and critical need. This should facilitate programme expansion based on a standard approach and common understanding.
• Capacity building, standardization, regulation and accreditation of the private sector should be strengthened. Training should continue for general practitioners with an emphasis on quality management of people living with HIV with limited financial resources.
• Policies and guidelines should continue to emphasize ethical and social aspects of care, support and treatment of people living with HIV. This includes issues such as acceptance of people living with HIV, equitable charging for services, strict adherence to informed consent and confidentiality of HIV testing, and ensuring safe blood supply.
• There should be greater involvement of people living with HIV in community- and home-based care services, including their policy development that will enable volunteers to progress into more senior roles within organizations.

4.23 Continuum of Care
    People living with HIV face various and changing prevention and care needs. These needs require continuing, timely and appropriate referrals from one service to another. Over the last several years, increasing attention has been paid to the care and support of people living with HIV as compared with earlier years when the predominant focus was prevention. Various care and support services are increasingly available with the review team receiving reports of referrals between hospitals, AIDS/STD teams, home-based care providers and NGOs. AIDS/STD teams are playing an important role to link and coordinate among the available services. These are however, based on individual arrangements and there is not yet any structure to coordinate these referrals systematically. Participation of people living with HIV remains limited. The establishment of continuum of care is also hampered by the lack of availability of a full range of services in each area. The lack of clear operational guidelines which describe the role of each stakeholder or the responsibilities of each level of health system in the locality is also an impediment.
    Recommendations for improving coordination and coverage of services at township level included:
• A coordinating body should be established at township level with the participation of public health, clinical and other stakeholders, including people living with HIV, in order to improve and expand referral practices, identify gaps/weaknesses in continuum of care and enable stakeholders to work collectively for township-based problem solving.
• The coverage of each essential service needs to be expanded since referrals and utilization can be improved only after they become available. Particular attention should be given to expanding access to OI management, ART, community and home based care, VCCT and PMTCT, through more widely utilizing existing public health facilities, NGOs and general practitioners.

4.24 Clinical Management
    Substantial progress has been made recently in several key areas of access to HIV clinical care. The initiation of ART programmes, initially in the non-profit private sectors and, more recently, in public health facilities, deserves particular mention. Supporting systems are being established at the central level, key protocols and guidelines have been written, training is being expanded and data systems established. Much work, however, lies ahead in areas of procurement and supply management, development of comprehensive training programmes and systematic support for new and existing ART sites. The number of people receiving antiretroviral therapy remains very low with an estimated coverage of only 4% of those in need at the end of 2005.
    The following actions are recommended:
• Development and strengthening of health systems to support the provision of HIV care including ART – with priority on supply management systems – and the development of a comprehensive national HIV care training programme are needed. Continuous and mentoring support for ART sites from the central level and local partners should be provided. Particular attention should be given to the care and treatment for children.
• Definition of a standard hospital HIV care team with clearly earmarked roles and responsibilities should be submitted to the Department of Health for approval. Local and central managers should advocate for staff to fill all positions in each HIV care team and devise strategies to retain staff in those positions. Training should be targeted at these teams.

4.25 Community and Home-Based Care
    Community- and home-based care for people living with HIV and affected families has been rapidly scaled up over recent years throughout the country.  There is an increasing recognition of these services being a key element of the continuum care required by people living with HIV. Although there is an increasing demand for community and home-based care and there is an increasing number of service providers, the coverage is still very low. There is also a marked diversity in the services offered by different implementing organizations. Only a few provide cotrimoxazole prophylaxis in their service package. In addition, there seems to be limited coordination of activities and some overlap in services provided to some target groups. Referral from home-based care to other services was observed in many areas but linkages with health care facilities are generally weak. There was limited evidence of involvement of people living with HIV in community-based care activities apart from their participation in support group activities.
    The following actions are called for:
• Development of a national standardized minimum package for community- and home-based care and operational guidelines may help to develop a working consensus model that could facilitate scale-up, provide guidance to less experienced providers and improve sustainability.
• The roles and responsibilities of the various actors involved in community and home-based care should be defined.
• The role of NAP in oversight and coordination rather that direct service provision should be considered.

4.26 HIV and Tuberculosis
    It is estimated that approximately 7% of adult tuberculosis (TB) patients are also co-infected with HIV. TB is reported  to be the leading opportunistic infection in people living with HIV with nearly 70% developing nearly active tuberculosis at some point of time. Formal structures for cooperation between TB and HIV programmes have been established and are currently active. Pilot projects are also contributing to programmatic learning. Access to VCCT for people with TB is a key intervention but is not offered in most areas. Strong informal mechanisms for co-management of people living with both diseases have emerged in some townships. The review team endorses the recommendations from the review of the National TB Control Programme, Myanmar, conducted in 6-17 December 2004.
• Formal collaboration between the NAP and the National Tuberculosis Programme with continuous information sharing, joint planning and development of policies, protocols and operational guidelines should be continued and strengthened. The coordination of TB and HIV services at the township level should be integrated into the continuum of care mechanisms rather than through separate formal processes.
• There should be rapid application of lessons learned from current pilot projects into programme implementation. The immediate priority at field level is funding and practical mechanisms to ensure that all TB patients are offered and that are able to access VCCT followed by referral for HIV care.
• Funding for both AIDS and TB programmes needs to be expanded needs to be expanded and sustained in order to support optimal management of people living with TB and/or HIV. Funding, implementation and monitoring should be incorporated into existing mechanisms of the national TB and AIDS programmes abrogating the need to establish specific TB/HIV mechanisms.

4.27 Reducing the Impact of HIV on the Life of Children, Adolescents and Adults
    Effective prevention, care and support programmes have significantly helped reduce the stigma and discrimination against people living with HIV. A wide range of activities have been planned and implemented to reduce ignorance and fear, and the consequent stigma and discrimination, through the mass media, the production of IEC (information, education and communication) materials, health education/talks in and out of school, peer education and the involvement of people living with HIV in awareness building and community education/
    Anecdotal evidence and the experience of implementers indicate that the number of orphans due to HIV is increasing, particularly in high prevalence townships. The review team learned that many of these infants and children either cared for or rejected by members of the extended family while some are institutionalized in a range of living dilatations by the Department of Social Welfare or faith-based organizations. There still remains a clear lack of attention and information about the numbers, location, situation and needs for a largely hidden population which is not capable of drawing attention to their situation.
    The AIDS epidemic has various socio-economic impacts on the life of children, adolescents and adults living with HIV, on their immediate families, friends and communities. This issue was an important part of the testimony of people living with HIV to the review teams in different parts of Myanmar.
    Recommendations made by the review team included that:
• Support should be extended to the self-help efforts to of people living with HIV through capacity building and group formation in the community
• There must be provision of vocational training, assistance in finding employment and funding for setting up local small-scale, income-generation activities in close  consultation with people living with HIV.
• Applied research should be conducted to support rapid action responding to the needs of orphans and vulnerable children. Community-based frameworks/programmes and mechanisms which bring together faith-based and community-based organizations and concerned government departments – including social welfare and health education –and well-linked to the health sector coordination should be encouraged.
• Access to ART must be expanded manifold as the most effective way of reducing stigma, preventing orphans and mitigating the socio-economic impact on people living with HIV and their families.

List of participants included in the original document but not included here.