Fund for HIV/AIDS in Myanmar: annual progress report 2006 - unaids

A n n u a l P r o g r e s s R e p o r t ,1 Apr 2006 - 31 Mar 2007Table of ContentsForeword 3About this report 5Highlights in Achievements 7Progress and Achievements 9....... Access to services to prevent the sexual transmission of HIV improved 9....... Access to services to prevent transmission of HIV in injecting drug use....... improved 18....... Knowledge and attitudes improved 27....... Access to services for HIV care and support improved 30Fund Management 41....... Programmatic and Financial Monitoring 41....... Financial Status and Utilisation of Funds 43Operating Environment 44Annexe 1: Implementing Partners expenditure and budgets 45Annexe 2: Summary of Technical Progress Apr 2004–Mar 2007 49Annexe 3: Achievements by Implementing Partners Round II, II(b) 50Annexe 4: Guiding principles for the provision of humanitarian assistance 57Acronyms and abbreviations 581

F u n d f o r H I V / A I D S i n M y a n m a rUNAIDS2

A n n u a l P r o g r e s s R e p o r t ,1 Apr 2006 - 31 Mar 2007ForewordThis report will be the last for the Fund for HIV/AIDS in Myanmar (FHAM), covering its fourth andfinal year of operation (the fiscal year from April 2006 through March 2007). Created as a pooledfunding mechanism in 2003 to support the United Nations Joint Programme on AIDS in Myanmar,the FHAM has demonstrated that international resources can be used to finance HIV services forpeople in need in an accountable and transparent manner. As this report details, progress hasbeen made in nearly every area of HIV prevention – especially among the most at-risk groupsrelated to sex work and drug use – and in terms of care and support, including anti-retroviraltreatment. While much more needs to be done, the FHAM has demonstrated that substantialprogress is possible, working with a variety of partners, including the Government, inside Myanmar.During 2006, several shifts occurred in the strategic and funding environment in Myanmar leadingto the closure and transformation of the FHAM. First, the Ministry of Health led, for the first time,a process involving national and international actors to develop collaboratively a National StrategicPlan that is inclusive of the work of all partners. The National Strategic Plan now overtakes theJoint Programme as the single reference document for partners working on HIV/AIDS. Secondly,donors, including those supporting the FHAM, saw that a modified version of the FHAM could beexpanded to cover more than just HIV, but also tuberculosis and malaria. This was particularlyimportant in the wake of the termination of the Global Fund grants, which left a serious fundinggap. Thus was created the Three Diseases Fund. Third, in response to lessons learned largelyfrom the FHAM but also as a result of the Global Fund termination, the Three Diseases Fund wasset up more independently from existing United Nations organizations, which have their ownprogrammatic and coordinating roles to play.As the Three Diseases Fund was being established, the FHAM was able, partly due to additionalsupport in 2005 from the Netherlands and in 2006 from AusAID, to extend partners’ portfoliosthrough to the end of April 2007 in order to accommodate the timing for the establishment of theThree Diseases Fund.Despite the good news of the establishment of the Three Diseases Fund, coverage of HIV preventionand care services in Myanmar remains insufficient. In most programme areas, only about 10percent of people in need are receiving appropriate services, with sex workers being perhaps themost important exception, where coverage may be closer to 50 percent. Yet, UNAIDS estimatesthat total resources for 2007 for HIV will decline as compared to 2006, even with the funding fromthe Three Diseases Fund. Under these circumstances, service coverage will not increase. Moreresources are therefore required, both from international sources and from Government.This year the United Nations Theme Group on AIDS has put resource mobilization on the top ofits list. This report shows that we can effectively combat the HIV epidemic in Myanmar - if theresources are adequate to meet the need.Daniel B. Baker, ChairUN Expanded Theme Group on AIDS3

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A n n u a l P r o g r e s s R e p o r t ,1 Apr 2006 - 31 Mar 2007About this reportThis report presents the achievements ofimplementing partners of the Fund for HIV/AIDSin Myanmar (FHAM) for the fiscal year 1 April2006 to 31 March 2007. This report is neither,therefore, a report on the HIV epidemic, nor areport on the wider national response to theepidemic in Myanmar.The FHAM was established in 2003 to resourcethe Myanmar Joint Programme on HIV/AIDS,and in the fiscal year 2006, donors contributingto the FHAM were the United Kingdom’sDepartment for International Development(DFID), Sweden’s Agency for InternationalDevelopment Cooperation (SIDA), theGovernments of the Netherlands and Norway,and Australia’s AusAID.The lifespan of the Joint Programme initially wasplanned for the period 2003-2005. However itsgoverning body, the UN Expanded Theme Groupon HIV/AIDS, agreed in December 2005 thatthe response to HIV could continue to beresourced and monitored using this frameworkuntil the new National Strategic Plan on HIVhad been established, and a new fundingmechanism was operational.During this year, the existing donors to theFHAM, with the European Commission, workedtowards the establishment of Three DiseasesFund to respond to AIDS, tuberculosis andmalaria in Myanmar. This funding mechanismwill supersede the FHAM. Therefore, insteadof making a further round of funding under theFHAM, existing projects funded by Round II(which was due to end on 31 March 2006), andwith a track record of performance, were giventhe option of extension beyond 1 April 2006,using unallocated FHAM resources, and finaldonor commitments and contributions. Thiswas with the aim of ensuring uninterrupteddelivery of essential services until the new fundwas operational. With this in mind, and withthe consent of the FHAM’s donors, the projectsof most existing FHAM partners were extendeduntil 30 April 2007. Most of the Three DiseasesFund’s agreed AIDS grants had a start date of1 May 2007. Following this same rationale, inthis fiscal year FHAM resources were used toprovide interim funding to extend service deliveryin six projects initiated with resources from theGlobal Fund AIDS grant, which was terminatedfrom 21 August 2006.This fiscal year 2006 report therefore covers anextension of implementation of projects fundedin Round II of the FHAM with additional funds,and the second year of implementation ofRound II(b) of the FHAM. At the beginning of2005, the FHAM issued a more targeted callfor proposals for Round II(b) of funding, with afocus on scaling up prevention services to reachkey populations at higher risk of exposure toHIV. These key populations comprise sexworkers and their clients, injecting drug users,and men who have sex with men. Round II(b)of the FHAM also aimed to increase access toAIDS care and support, including antiretroviraltherapy.Funding rounds of the FHAM and their duration.5

F u n d f o r H I V / A I D S i n M y a n m a rUNAIDSDuring this reporting period, the developmentof the Myanmar National Strategic Plan (with atargeted, costed Operational Plan) wascompleted, from which prioritised activities wereto be supported by the Three Diseases Fund.In the interim, in anticipation of the availabilityof the new funding mechanism, the FHAMcontinued to operate within the framework ofthe Joint Programme on HIV/AIDS in Myanmar.The Joint Programme identified five priority areas(Components) for action, with five primaryoutputs:1. Access to services to prevent thesexual transmission of HIV improved2. Access to services to preventtransmission of HIV in injecting druguse improved3. Knowledge and attitudes improved4. Access to services for HIV care andsupport improved5. Essential elements of the enablingenvironment for an effective expandednational response strengthenedWhere possible, it is indicated in the text ofthis report how the outputs of the JointProgramme Components relate to the StrategicDirections of the Myanmar Strategic Plan onHIVAIDS (see box below).While the Joint Programme aimed throughComponent 5, “to strengthen the essentialelements of the enabling environment for aneffective expanded national response” - throughadvocacy, improving monitoring and evaluation,capacity building, and improved coordination –this report focuses on the four main servicedeliveryComponents and describes theComponent 5 strategies in the context of therelevant Components 1 to 4. For example,training for health care professionals onsubstitution treatment for injecting drug usershas been reported in the related output,prevention of transmission of HIV in injectingdrug use. Non-exhaustive lists of manuals andguidelines developed with FHAM funding andnot mentioned in earlier sections are includedas an annexe.Strategic DirectionsMyanmar National Strategic Plan on HIV and AIDS 2006-20101. Reducing HIV-related risk, vulnerability and impact among sex workers and their clients2. Reducing HIV-related risk, vulnerability and impact among men who have sex with men3. Reducing HIV-related risk, vulnerability and impact among drug users4. Reducing HIV-related risk, vulnerability and impact among partners and families ofpeople living with HIV5. Reducing HIV-related risk, vulnerability and impact among institutionalised populations6. Reducing HIV-related risk, vulnerability and impact among mobile populations7. Reducing HIV-related risk, vulnerability and impact among uniformed services personnel8. Reducing HIV-related risk, vulnerability and impact among young people9. Enhancing prevention, care, treatment and support in the workplace10. Enhancing HIV prevention among men and women of reproductive age11. Meeting needs of people living with HIV for Comprehensive Care, Support and Treatment12. Enhancing the capacity of health systems13. Monitoring and evaluation6

A n n u a l P r o g r e s s R e p o r t ,1 Apr 2006 - 31 Mar 2007Highlights in AchievementsThe fiscal year 2006, the fourth and final year ofthe FHAM, has seen further scale-up in serviceprovision for HIV prevention and AIDS care inMyanmar by FHAM implementing partners.1. This year the programme continued tofocus on key populations at higher riskof exposure to HIV.a. 10,280 injecting drug usersreached through FHAM projects,a fourfold increase on last year. Sixdrop-in centres were addedbringing the total of FHAM fundedlocations to twelve at the end ofthis year.b. 424,091 people at higher risk ofinfection reached through 83,841HIV prevention education sessions,an increase of 30% on last yearfor both people reached andsessions held.c. Two new drop-in centres have beenestablished to reach sex workersand men who have sex with men.2. The number of individuals receivingantiretroviral therapy in FHAMsupportedprojects has doubled thisyear, to reach 6,116 at the end of March2006. This represents approximately10% coverage of the estimated numberof persons in need of antiretroviraltreatment.3. Provision of home-based care has seensteady scale-up during this year toreach 9,450 persons, an increase of82% on the previous year.4. Methadone treatment was madeavailable near the end of the lastreporting period, and at the end of thisyear 264 patients were enrolled in theprogramme. The start of the methadoneprogramme in Myanmar represents asignificant milestone in serviceprovision for the particularly vulnerablepopulation of injecting drug users, bothin prevention of HIV transmission andalso the hope of greater access for thispopulation to AIDS care servicesincluding antiretroviral therapy.5. The number of individuals receiving HIVtest results, thereby completing thevoluntary counselling and confidentialtesting process, more than doubled toreach 77,659 in the year. In-house HIVtesting is now available through theprogrammes of two eligible INGOpartners, representing a positivechange in regulations.6. Total condom distribution was similarto the previous year, with 43.7 millioncondoms distributed. This year theproportion of condoms distributed freeincreased.7. Needle and syringe exchange forinjecting drug user beneficiaries ofFHAM-supported projects increasedwith over five times the number of unitsof sterile injecting equipmentdistributed compared with the previousreporting period.8. The number of clients accessing STIservices during this year rose by 90%to 397,000. This is widely thought toreflect an increase in providers ofquality treatment and awareness ofservices, as prevalence has beenshown to have decreased.9. Services for the prevention of motherto-childtransmission of HIV have beenestablished in 14 additional townships,bringing the total of FHAM-supportedtownships to 26. The number ofmother-baby pairs receiving Nevirapineprophylaxis, while small, has doubledevery year to reach 409.7

F u n d f o r H I V / A I D S i n M y a n m a rUNAIDSAchievements made in support of the responseto HIV included:10. Capacity building support to empowerCommunity-based Organisations torespond to HIV in their communitieshas been provided by Alliance andBurnet Institute, including seed grantsto 15 partner projects.11. Two substantial reviews were fundedthis year to inform the nationalresponse to HIVa. A thematic review of peereducation approaches for HIVprevention in Myanmar wasfacilitated by UNAIDS with theparticipation of FHAMimplementing partners andstakeholders.b. A review of the prevention ofmother-to-child transmission ofHIV (PMCT) programme wasconducted jointly by NAP,UNFPA, WHO and UNICEF.12. A planning process was undertaken,with agreement of the donors, to ensurecontinuity and avoid scale down ofservices during the start-up of the ThreeDiseases Fund, by extending projectsfunded through Round II of the FHAM.Extensions were assured from 1 Apriluntil end November 2006, then from 1December 2006 to 31 March 2007, andfinally from 1 to 30 April 2007. Projectshad to have demonstrated a soundhistory of performance to be eligible forextension.13. Interim funding to maintain essentialservices initiated with Global Fundresources was realised for six AIDSgrantprojects. Three of these wereINGO partners, starting from August2006, and three were national NGOprojects, starting December 2006.14. Expenditure of FHAM funds recordedin the fiscal year 2006 amounted to US$9,345,116 - 47% higher than in 2005.15. Fourteen monitoring trips were madeto visit the implementation sites of 19FHAM partners this year to 21townships. Ten of the 14 visits includedmonitoring of National AIDSProgramme FHAM-supportedactivities, and three were made jointlywith staff monitoring implementation ofGlobal Fund supported services in thesame townships.8

A n n u a l P r o g r e s s R e p o r t ,1 Apr 2006 - 31 Mar 2007Progress and AchievementsAccess to services to prevent the sexual transmission ofHIV improvedTwenty projects funded by the FHAM have beenworking for the prevention of sexualtransmission of HIV (Component 1 of the JointProgramme). The two main outputs areincreased access to condoms and increasedcapacity for the prompt and effectivemanagement of Sexually Transmitted Infections(STI). Outputs from this component supportseveral Strategic Directions in the MyanmarNational Strategic Plan on HIV, and especially:Reducing HIV-related risk, vulnerability andimpact among sex workers and their clients(Strategic Direction 1); men who have sex withmen (2); drug users (3); young people (8).Access to affordable condoms for sexually active men, women and young peopleincreasedThe majority of new HIV infections in Myanmarare transmitted sexually, and increasing accessto affordable and quality condoms, and informingon correct and consistent use remain keyobjectives of the response to HIV. FHAMfunding has contributed to the distribution of 43.7million condoms this year, a slight increase onlast year. Of these, 28.8 million were distributedby Populations Services International (PSI). PSIuses FHAM funding to support the distributionand marketing of all condoms, but the condomsare purchased using funds from multiplesources. PSI reported that 5.2 million of thecondoms distributed were purchased withbudget from the FHAM.Chart 1.19

F u n d f o r H I V / A I D S i n M y a n m a rUNAIDSTwenty implementing partners including theNational AIDS Programme (NAP) have providedcondoms, through free distribution to keypopulations at higher risk of infection and toyoung people, as well as the social marketingof affordable male and female condoms andlubricants nationwide (chart 1.1). Freedistribution of male condoms increased in thisyear, while PSI reported leakage of unbrandedcondoms and free distribution into the privatesector, which had an impact on the routinedistribution of socially marketed Aphaw brandcondoms. When coupled with a short-termoversupply to the wholesalers and Chinesecondoms flowing into the market, there was a12% decline in PSI sales. However the Chinesecondoms are illegally imported and do not bearany certified test recommendations.Nonetheless, compared with last year, PSIreported increases in sales of female condomsand lubricants. Female condom sales were 2.6times higher and were mostly due to targetedpromotion and direct sales to sex workers andmen who have sex with men. Sales of lubricantsachets increased 37% on last year, and weredistributed through INGOs, wholesalers andmore than 10,000 retailers.Condoms have been distributed in both urbanand rural areas to groups including sex workers,their clients, men who have sex with men, STItreatment seekers, male mobile workers,seafarers, and in the workplace. Partners haveestablished supply systems with outlets in awide range of locations, and reported distributingdifferent kinds of condoms adapted to the needsof their beneficiaries - flavoured, packed withlubricant gel, and female condoms. Condomshave also been distributed in AIDS care andsupport projects, promoting condom use bypeople living with HIV in a ‘Positive Prevention’strategy.The International HIV/AIDS Alliance (Alliance)reported high demand for condoms from specifictarget groups of their projects (sex workers, menwho have sex with men, and people living withHIV) and that the number of condoms distributedincreased significantly this year. Condoms werepurchased from PSI social marketing outletsand distributed free to key populations at higherrisk.The Myanmar NGO Consortium on HIV/AIDS(Consortium) provided condoms to keypopulations at higher risk, youth, and to thegeneral population, and reported an increase indemand for condoms from sex workers and theirgate keepers, with around 28% more condomsbeing distributed to this target group comparedwith last year. Condoms have been provided tosexually active youth and also to uniformedservices personnel. In its project area in Waregion, Malteser distributed condoms tohighway truck drivers, and at health centresincluding those of its partner Health Unlimited,and at market days. MBCA and PARTNERSdistributed condoms free of charge in theirworkplace projects through education sessionsand peer educator networks. Peer educatorsin MBCA’s workplace projects aim to improveattitudes towards condoms and teach skillsrequired for correct and consistent condom use.MRCS distributed condoms to young peopleand general community in rural and urban areasof its project townships through a peer-basedapproach, and with condom demonstration.MRCS reported improved knowledge amongyoung people of where to find condoms and ofproper condom use, and that knowledge of safersex practices had improved among youngpeople in its project townships.During the reporting period, MSF-Hollanddistributed condoms in STI clinics, to injectingdrug users, people living with HIV, people athigher risk of infection, and during healtheducation activities. A regular supply schemehas been established in order to ensure condomavailability and promote condom use inentertainment places.PSI has continued its mass media campaignfeaturing its chameleon mascot Pothinnyo,appearing on television and billboards, injournals and IEC materials, to deliver Aphawcondom-use promotion messages. PSI alsoreported that its Targeted Outreach Program hasbecome increasingly community-centred andnow run mostly by its own members - sexworkers and men who have sex with men.The NAP continued to implement the 100%Targeted Condom Promotion (100% TCP)programme this year, and increased coverageto additional townships with financial supportfrom the Global Fund. The programme now10

A n n u a l P r o g r e s s R e p o r t ,1 Apr 2006 - 31 Mar 2007extends to 170 townships. NAP reported thatsuccessful implementation of 100% TCP at thetownship level depended on the cooperation withthe law enforcement sector in the locality. WHOparticipated in monitoring visits to Loikaw,Lashio, Mandalay and Yangon, and providedtechnical support for the development of thenational guidelines on 100% TCP thatincorporate recommendations provided by theexternal review of the programme in 2005.11

F u n d f o r H I V / A I D S i n M y a n m a rUNAIDSCapacity for the prompt and effective management of Sexually TransmittedInfections (STI) increasedThis year a 90% increase in the number ofclients attending STI services was reported, aswas a 75% increase in referrals. The NAPcontinued to provide diagnosis and treatmentof STI through its network of 45 AIDS/STDteams, and to provide supplies (to healthfacilities in 310 townships) and capacity buildingto basic health staff at township level. This year,57% of the 93,000 clients treated in the publicsector were female. The NAP conducted threetraining-of-trainers workshops for the syndromicmanagement of STI in Taunggyi, Myitkyina andKyaingtong for Medical Officers with 96participants. Subsequently 48 multipliertrainings on syndromic management werecarried out in Eastern and Southern Shan andKachin states for Basic Health Staff (40participants in each training).Chart 1.2The number of clients treated in the NGO sectorcontinued to increase (chart 1.2). This yearthe number of service delivery points providingdiagnosis and treatment of STI increased by30%, largely due to increased numbers of SunQuality Health practitioners supported by PSI.Overall, PSI reported an increase of 5% in thenumber of clients treated for STIs. STI diagnosisand treatment was also available in 5 drop-incentres providing services especially to sexworkers and men who have sex with men.Operational feedback from Sun clinics showedthat many were still reluctant to use benzathinepenicillin injection for syndromic treatment ofgenital ulcer, that increased numbers of vaginaldischarge syndrome in female clients weretreated, and that increasing numbers of urethritiswere not relieved by the “Cure U” kit. Eventhough it was promoted, there was a low rate ofpartner treatment. In addition, many healthproviders reported a decrease in client numberson the previous year.12

A n n u a l P r o g r e s s R e p o r t ,1 Apr 2006 - 31 Mar 2007The number of clients treated for STI at the 11MSI centres increased by over 55% from lastyear, with 16% male and 84% female STIclients, while around one third of clients wereyouth. MSI continued to provide STI treatmentto sex workers both in its centres and byoutreach, leading to significantly more sexworkers (estimated at around 60% of brothelbased sex workers in the MSI townships)accessing and receiving treatment. MSIreported an increase in health seeking behaviour,and greater confidence among clients torequest, carry and use condoms, particularlyin key populations at higher risk, and youth.MSF-Holland has continued to provide servicesfor early diagnosis and treatment of STI throughits 18 clinics in Yangon Division (Hlaingthayar,Taketar and Insein townships), Kachin State(Myitkyina, Bhamo and Hpakant), Shan State(Lashio, Muse and Laukkai in Kokang region)and Rakhine State (Maungdaw, Buthidaung andSittwe). During the reporting period, the numberof patients coming for diagnosis and treatmentof STI increased in all locations. MSF-Hollandalso provided services through outreach to sexworkers in brothels and massage parlours asthey are sometimes are not able to attendclinics. In 2006, depending on the location,30-80% of the STI patients treated were fromkey populations at higher risk.AMI reported that the number of male andfemale clients seeking STI treatment in itsclinics increased in the year since the AMIclinics were re-opened and that stigma anddiscrimination towards STI care seekers haddecreased in Seikki and Twantey throughstrengthening health education on the subject.However, some misconceptions about STI werestill prevalent and would be continue to beaddressed through AMI’s peer education project.Malteser continued to operate its STI clinic inPang Kham in the Wa special region of ShanState.Médecins du Monde (MdM) received interimFHAM funding from August to December 2007to continue to provide services started withGlobal Fund resources, including drop-incentres and outreach to sex workers in Yangonand Kachin State. Sex workers were able toaccess STI treatment, HIV counselling andtesting, and also treatment for opportunisticinfections through MdM’s project.The Alliance reported high demand for STIdiagnosis and treatment when adequate supportfor referral and treatment is provided. In areaswhere NGO centres or NAP AIDS/STD teamsare present, the projects were able to referpatients to these services. However, in areaswhere free NGO or public services were notavailable, the project referred patients to privatepractitioners, with a preference for Sun Qualitypractitioner clinics. In such cases, the Alliancepaid for diagnosis and treatment.This year, WHO completed the development ofSTI national standard guidelines, STI flow chartsand STI treatment handbooks, which wereapproved by the Ministry of Health anddistributed nationwide by NAP. An STImonitoring tool was developed and a workshopon its utilisation organised, although its wideruse has not yet been confirmed by the NAP.13

F u n d f o r H I V / A I D S i n M y a n m a rUNAIDS14

A n n u a l P r o g r e s s R e p o r t ,1 Apr 2006 - 31 Mar 2007Positive attitudes, safe sexual behaviours and practices in key populationsClosely linked to condom promotion and STIservices in the prevention of the sexualtransmission of HIV, 10 partners have beenworking to improve attitudes, behaviour andpractices in key population groups at a higherrisk of exposure to HIV. These include sexworkers and their clients, men who have sexwith men, and the partners of injecting drugusers. Activities include counselling, behaviourchange communication, health educationsessions, often using outreach and a peereducation approach. These activities fell withinComponent 3.2 of the Joint Programmeframework, but will be described here in thecontext of prevention of sexual transmission ofHIV, more in line with the Myanmar NationalStrategic Plan on HIV, for which strategicdirections have been formulated based on keypopulation groups.Some 83,841 health-education or counsellingsessions for populations at higher risk wereachieved, reaching 424,091 persons. Chart 1.3compares sessions held for vulnerable groupsduring the three years of Round II of the FHAM.Drop-in centres have been established for sexworkers and men who have sex with men andhave proved very popular with clients (AMI,Consortium, PGK, PSI). Townships withprojects to reach sex workers are shown in themap on page 17. Townships were selected onthe basis of NGOs having authorization to workthere, and as planned in the approved FHAMproject proposals. Partners have reported beingable to gain the confidence of beneficiaries,including sex workers, their gatekeepers andowners of entertainment venues. The Alliancehas been supporting informal networks of sexworkers and men who have sex with men forHIV prevention messages and services.Chart 1.315

F u n d f o r H I V / A I D S i n M y a n m a rUNAIDSBy the end of March 2006, PSI reported 82 peereducators actively involved in drop-in centres inYangon, Mandalay, Taunggyi, Pathein, BagoHinthada, Meikhtilar, Kalay, Myitkyina andTaungoo.AMI had 84 peer educators among sexworkers and men who have sex with men, in itsdrop-in centre and project townships in YangonDivision.The Consortium reports one figure that includesoutreach staff with peer educators, whichcontributes a sizeable number to the total of1,368 reported, and therefore to the totalnationwide. This change in reporting isreflected in chart 1.4, by a sizeable increaseduring the first quarter of 2005 in the number ofpeer educators working with at-risk populations.Chart 1.4Two international expertise agencies, theInternational HIV/AIDS Alliance and BurnetInstitute’s Centre for International Health, haveprovided technical and financial support throughseed grants to CBOs to work with sex workersand men who have sex with men. Four projectsfor peer education among sex workers have beensupported by the Alliance in Pyay,Mawlamyaing and Kyaukpadaung. The BurnetInstitute has worked closely with Pyi Gyi Khinto provide a comprehensive package oftechnical support and capacity building for HIVprevention and care among sex workers andmen who have sex with men. The Alliance hasfacilitated formation of informal self-help groupsof men who have sex with men, building onstrong community networks locally. Self-helpgroup leaders have proved to be highly motivatedto work on HIV prevention and care, havingwitnessed many community members affectedby HIV. As these are informal groups, capacityto implement HIV projects was low, and hasbeen strengthened through peer discussiongroups on issues that affect the vulnerability ofmen who have sex with men to HIV. The groupspromote solidarity and community normstowards safer sex. The Alliance has alsosupported Pyi Gyi Khin by training staff andpeer educators in their project in Myingyan formen who have sex with men. Informal groupshave been mobilised in Yangon, Mandalay,Monywa, Kyaukpadaung, Pyay, Magway,Mawlamyaing and Myingyan.NAP’s 100% TCP programme included trainingof sex workers as peer educators, and a reviewof peer education strategy for sex work wasplanned this year in order to providerecommendations and training tools.Unfortunately this had to be cancelled when theconsultant became unavailable shortly beforearriving.16

17A n n u a l P r o g r e s s R e p o r t ,1 Apr 2006 - 31 Mar 2007

F u n d f o r H I V / A I D S i n M y a n m a rUNAIDSAccess to services to prevent transmission of HIV in injectingdrug use improvedIn this period, six implementing partnershave been working with support from theFHAM to increase access to servicespreventing transmission of HIV amonginjecting drug users (Component 2 of theJoint Programme). They comprise onegovernment department (DoH), two UnitedNations organisations, two internationalNGOs and one national NGO. Partnerswork towards the aims of this componenteither by direct service delivery to reachdrug users through outreach activities anddrop-in centres (AHRN, MANA, UNODC),or by provision of coordination or technicalassistance (NAP; BI-CHR, UNODC,WHO). In the Myanmar National StrategicPlan on HIV, activities previously regroupedunder this component now compriseStrategic Direction 3, Reducing HIV-relatedrisk, vulnerability and impact among drugusers.Townships:UNODC – Lashio, Muse, Theinni, Tang Yan, (Northern Shan State);Tachileik (Eastern Shan State)AHRN – Lashio and Kone Nyaung (Northern Shan State)MANA – Lashio 3 sites; Naung Mon, Nan Paung (rural sites), Ward9 (urban site); Yangon 2 sites; Yankin and TamwetownshipsMdM – Myitkyina, Moegaung (Kachin State)Access to harm reduction interventions increasedThe main beneficiaries in this Output areinjecting and non-injecting drug users and theirpartners, families and communities in prioritisedtownships. This year has seen a significant,almost fourfold increase in the number ofinjecting drug users reached, and a doubling ofthe number of centres functioning with FHAMfunding. Distribution of sterile injectionequipment also increased accordingly over theperiod (chart 2.1).18

A n n u a l P r o g r e s s R e p o r t ,1 Apr 2006 - 31 Mar 2007Chart 2.1Three new drop-in centres were established inNorthern Shan State this year - Kone Nyaung(AHRN), Tang Yan and Theinni (UNODC).Another centre was opened in Tachileik inEastern Shan State (UNODC sub-contract toMANA). Two of MANA’s centres in Yangon thathad been supported by the Global Fund receivedinterim FHAM support from December onwards.The six additional centres have increased thegeographical coverage and access to apackage of services, including the provision ofsterile injecting equipment and disinfectionmaterials through the centres and outreach.Drug users are referred to Drop-in Centresthrough outreach. UNODC reported that thepermission to expand was largely attributableto a continuous focus on advocacy. Involvementof central and local authorities had garneredsupport for needle and syringe programs indesignated communities. The concentration ofservices in Lashio township especiallyincreased. However, AHRN had planned fourdrop-in centres in Round II(b) of the FHAM, butpermission for two centres in Laukkai and Kalaywas not yet granted.With the conclusion of the Global Fund projectin Myanmar, the FHAM supported Médecins duMonde (MdM) to maintain services on injectingdrug use in Kachin State from September tothe end of 2006, when MdM identified alternativesources of funding for 2007. In addition UNODCreprogrammed some of its FHAM budget toprovide stop-gap funding to its implementingpartners, CARE and MdM, in UNODC’s “G54”project, which had been funded by the EuropeanCommission. This extension covered the lattersix months of 2006, until alternative resourceswere mobilised and made available at thebeginning of 2007.This year, AHRN and UNODC were unable toexpand activities in the timeframe planned, dueto issues around permission, resulting in lowerachievements than expected for needle andsyringe distribution. Nevertheless, FHAMfunded needle and syringe distribution more thanquadrupled the previous year’s figure. Inaddition, the number of injecting drug usersaccessing services through drop-in centres washigher than anticipated, attributed in part to thehigh utilisation of primary health care servicesoffered. Provision of primary health care hasprovided inroads to reaching marginalisedpopulations, developing trust and access toother services. The number of non-injecting drugusers accessing health care also exceededtargets. Establishing contacts with this groupwas considered important as HIV infection oftenoccurs soon after an individual makes thetransition to injecting. Drug users who havenot yet made this transition are a key group toreach with prevention and risk minimisationmessages.The numbers and topics of health educationsessions increased over the past year, includingnot only drug users as participants, but alsopartners, family members, and other peoplefrom the community. Partners providedinformation on subjects including HIV, HepatitisB and C, safer injecting practices and condomuse.AHRN reported that regular peer educationsessions also helped to identify and involve drug19

F u n d f o r H I V / A I D S i n M y a n m a rUNAIDSusers and former users in projectimplementation, and that this influenced thegrowth of the so-called ‘Black Sheep Group’,an informal self-help group of drug users andex-users, closely linked to the AHRN project inLashio. The involvement of drug users as peereducators reportedly met with resistance fromthe community and the authorities. Althoughpossible, it remained sensitive and could notbe implemented to the extent planned. In future,on potential solution would be to involveindividuals on methadone, but since theprogramme in the early stages there is currentlya limited number of candidates in Lashio.AHRN reported holding separate, monthlyhealth-education sessions for female drug usersto help address the specific gender sensitivitiesand confidences. AHRN recruited one femaleoutreach worker and one needle patrol/peereducator in 2006. The number of female drugusers reached by the project has increasedfourfold monthly and AHRN was able to adaptservices such as counselling and health careto their needs.MANA reported that courses in relaxation andmeditation had been offered by a Buddhistreligious teacher in its Yangon centres. MANAalso supported 15 beneficiaries in Yangon forvocational training experience in carpentry anda coffee shop. Two partners reported thatreintegration and rehabilitation of drug userscould only be maintained in the long term ifextensive income generation activities were setup and that securing the funding needed for thisremained a challenge.AHRN aimed to increase access to condomsusing multiple outlets. Every outreach packwith sterile injecting equipment includes acondom, condom boxes were placed in drop-incentres and in contact points including teashops,cinema, and billiards stations.Partners in Lashio expanded a mutual referralsystem to make more specialist health careavailable to clients as necessary. This includeddetoxification, methadone maintenancetreatment, rehabilitation, tuberculosis treatment,HIV testing, anti-retroviral therapy, and to moregeneral health care such as hospital-basedtreatment for common illnesses. Increasednumbers of VCCT referrals were reported thisyear. UNODC reported that a number ofbeneficiaries were referred to anti-retroviraltreatment providers during this year, reflectingthe increase in availability of treatment.However, it was not reported if referrals resultedin any beneficiaries commencing anti-retroviraltreatment. UNODC’s Lashio Outreach Projectreported that, during the last quarter, 90% ofindividuals tested returned for post-testcounselling. MANA, MDM, and AHRN alsoprovided HIV pre- and post-test counselling withreferral for HIV testing.Operational research findings reported• Lashio Outreach Project reported that 36% of clients tested HIV positive andsuggested that this is in line with estimated national prevalence among injectingdrug users.• MANA reported 32% HIV positive among 433 persons receiving test results. Somevariation in percentage between centres was reported, from 14% in Yangon to53% in Nan Paung, with Lashio Ward 9 reporting 37%, similar to the 36% reportedby the Lashio Outreach Project.• MANA reported that a study of 96 clients in Northern Shan State revealed that99% were heroin users, and that 98% of these injected, of whom 85% wereinjecting two or more times daily.20

A n n u a l P r o g r e s s R e p o r t ,1 Apr 2006 - 31 Mar 2007• In contrast, a study in MANA’s Yangon centres showed that 87% of clients areformer users, most of whom had injected in the past, but were now using alcohol,with or without cannabis or diazepam. Only 13% of clients were active drug users.Low availability of heroin in Yangon was reported as a factor for the lower percentageof users, and this combined with the availability of needles and syringes for purchasein Yangon was a reason for low uptake of injecting equipment at the centres.• A UNODC impact study described increased health seeking behaviour bybeneficiaries, while risk behaviours including use of non-sterile injecting equipmentboth at onset and for ongoing drug use, buying sex, and unprotected sex werereported to be declining in project areas.• A UNODC baseline survey in Theinni reported that drug users were sexually active,contrary to the perception of many, and that risk behaviours in relation to sexualtransmission were prevalent, with the majority of drug users not using condomswith partners. Although FHAM implementing partners working with drug usershave been providing condoms, some reported low demand and uptake.• UNODC reported reduced frequency of use of non-sterile injection equipment inLashio. Use of non-sterile injection equipment at onset of injecting was reported tohave declined from 47.6% in the late 1990s to 23.4% in 2005, while use at the lastinjection reportedly declined from 50% among users who started injecting in thelate 1990s to 8.4% among users who started injecting in 2005.• Although use of amphetamine-type stimulants (ATS) is reportedly becoming moreprevalent, services have as yet not been adapted to deal with this. This will have tobe addressed in the future, especially considering the correlations that are emergingbetween ATS use and risky sexual behaviour.21

F u n d f o r H I V / A I D S i n M y a n m a rUNAIDSAdvocacy and the operating environmentUNODC and partners have been supporting themodel of the Township Steering Committee,which involves local authorities in decisionmakingand project implementation, contributingto an enabling environment for services.Advocacy for authorities and communities onissues relating to HIV and drug use has beencontinuous throughout the life of the FHAM,facilitating expansion to new sites and for newservices, including methadone.22

A n n u a l P r o g r e s s R e p o r t ,1 Apr 2006 - 31 Mar 2007UNODC and AHRN jointly planned a series ofadvocacy events for health and law-enforcementofficials. A two day seminar on “LawEnforcement and Public Health: DevelopingPartnerships to Combat the Harmfulconsequences of Drug Use” was held in NayPyi Taw, with a range of experts that includednational participants and seven speakers fromIran, China, Hungary, Belgium, Australia andIndia. In September, UNODC partnered withthe Ministry of Health and the CCDAC tofacilitate a ten-day “Joint AssessmentConcerning Law Enforcement, HIV and DrugUse”. A study tour in December to observe HIVand drug use initiatives in Vietnam involved 30representatives from government and NGOs.Another to Iran for HIV initiatives in prisons wasconducted in March and included high-levelrepresentation from the Ministry of Health andthe Ministry of Home Affairs, with two delegatesfrom the Myanmar Prisons Department.FHAM partners working in HIV and drug useparticipated in the overall drafting process ofthe Myanmar National Strategic Plan on HIVand Operational Plan, most specifically in thestrategies related to drug use, prisons anduniformed services. High priority has been givento the prevention of transmission of HIV in druguse in these Plans.Despite the advocacy efforts, the environmentremained constrained for much of 2006. Travelauthorizations for expatriates were difficult toobtain as was permission to implement newactivities. Uncertainties about the level ofsupport by the Ministry of Home Affairs for harmreduction grew. The transfer of Memoranda ofUnderstanding from Home Affairs to the Ministryof Health was finally approved towards the endof this reporting period, however, and travelauthorization and certain permit issues hadalready begun improving since November 2006.Authorization was granted for additional sitesin Northern Shan State (Kone Nyaung and TangYan).Nevertheless, challenges remain. One partnerreported that in Lashio township, visits betweenorganisations for any staff (local or expatriate)require prior permission from the local townshipauthority. This is in addition to the central levelauthority required for expatriate staff. Theauthorities’ system of allocation of wards toprojects in Lashio also limited the ability to reachsome hidden drug users, while frequentcrackdowns on drug using and selling placessometimes affected relations between injectingdrug users and outreach staff. It was reportedthat in local authorities Mandalay restrictedharm reduction activities.Capacity building and technical assistance for national partners• During the year, guidelines developed byWHO on Primary Health Care services forInjecting Drug Users were approved, printedand distributed to Drug Treatment Centres,township hospitals and NGOs in locationswhere services are being provided.• BI-CHR was also involved in mentoring forproposal writing and also for coachingMANA staff from 7 field sites. A new MANA-UNODC site opened in Tachileik and aneeds assessment with subsequenttrainings were done there by BI-CHR.• The partnership between MANA and theBurnet Institute’s Centre for Harm Reduction(BI-CHR) continued to grow this year. MANAundertook a process of organisational restructuringand developed a strategic planfor 2006-10 as well as an operational plan2007-10 with support from BI-CHR. MANAreported that the whole project working teamhad been strengthened by the continualtechnical assistance and capacity buildinginputs.• BI-CHR staff also made site visits andprovided mentoring for project staff from theAsian Regional HIV/AIDS Project (ARHP),CARE, and MdM. With two FHAMimplementing partners, significantdiscussions included the appropriate useof prescription drug medication for drugusers, and the difference between casemanagement and counselling.23

F u n d f o r H I V / A I D S i n M y a n m a rUNAIDS• BI-CHR hosted seventeen formal trainingworkshops this year on subjects includingDrug Use Patterns in Myanmar, CommunityResponse to the HIV Epidemic, Introductionto Alcohol and other Drugs Counselling,Amphetamine-type Stimulants, Drugs andSociety, Management Information System.A number of organisations working in HIVand drug use participated in theseworkshops, including MANA, MdM, CARE,ARHP, AHRN, MSF-Holland.• MANA reported that training and technicalassistance were also provided by theNational AIDS Programme, and ARHP, withadditional assistance from the UN agenciesUNODC and WHO. Community leveltraining on prevention of HIV infectionamong partners and families of drug userswas provided with the assistance ofUNFPA.• AHRN contributed to capacity building andcoaching of staff from other implementingpartners in HIV and drug use (MANA, MdM,CARE, UNODC-Lashio Outreach Project,ARHP), and reported that since communitybasedservices in this sector are stillrelatively new in Myanmar, there is aconstant need to build the technicalcapacity of project staff.• This year BI-CHR finalised, printed anddistributed the Harm Reduction Operationsmanual for Myanmar to all partners in bothMyanmar and English language versions.The availability of the final Myanmarlanguageversion was delayed due todifficulties in translation of the technicallexicon of harm reduction. BI-CHR reportedthat there would be continual follow-up onthe use of this manual with future revisionsmade as appropriate. BI-CHR alsocompleted the development of theManagement Information System in thisperiod. The finalisation process included 5stakeholder workshops, and the tool wassubsequently field-tested by 6 partnerorganisations before being distributed to allpartners.24

A n n u a l P r o g r e s s R e p o r t ,1 Apr 2006 - 31 Mar 2007Access to and quality of drug treatment in institutional and non-institutionalsettings improvedThe methadone programme expanded this yearto include 264 patients by the end of March2007, exceeding the target of 200. During thelast year, the Department of Health opened twonew dispensing sites, one in Bamaw (KachinState) and one at the Thingangyun hospital inYangon making a total of six sites. WHOorganised monitoring visits jointly with theDepartment of Health to dispensing sites inLashio, Mandalay and Yangon this year, andfacilitated collaboration between the Departmentof Health and the NGOs. In all areas wheremethadone services are available, there is activereferral by NGOs so their clients can start tobenefit from the programme. More referrals todrug treatment services from outreach projectswere reported in this year, especially in Lashiowhere, for example, UNODC reported that 10referred clients were on methadonemaintenance therapy. However, authorizationfor NGOs to be dispensers of methadone asoriginally planned was not granted, and this islikely to limit the ability to scale-up coverage ofthe treatment programme. Methadone wasprocured with FHAM funds to provide a stockcover for 2007 by WHO as well as by UNODC.A number of drug users were also referred fordetoxification treatment, although the numberthat completed the detoxification process wassignificantly lower. In Lashio, this was relatedboth to the limited ability of projects to supportclients during inpatient stays at the DrugTreatment Centre, and to the availability ofsymptomatic treatment on an outpatient basis.However, other areas including Theinni andMuse have neither an accessible DrugTreatment Centre nearby, nor facilities thatprovide outpatient services. As such, furtherdevelopment of drug treatment options isneeded. MANA reported that only two clientshad been referred to the Drug Treatment Centrein Yangon, and that most other clients preferredto take a seven-day symptomatic treatmentdispensed at their Yangon drop-in centres.Capacity building events• WHO, the National AIDS Programme andthe Department of Health’s Drug AbuseControl Project co-organised a workshopon common technical issues on methadonemaintenance treatment and HIV/AIDS care,in particular ART, for injecting drug users.Psychiatrists participating in themethadone programme and cliniciansinvolved in ART provision from Yangon,Mandalay, Shan and Kachin State, andNGO representatives discussedopportunities and challenges in the provisionof methadone and ART for injecting drugusers. During training sessions organisedfor health care workers on methadonemaintenance therapy, participation of expertpatients was introduced to the teachingmethodology.• UNODC and AHRN led a study tour to HongKong to introduce six participants to theHong Kong model of methadone provision.• UNODC organised training on Drug AbuseCounselling and Motivational Interviewing inFebruary in Yangon to build the capacity of25

F u n d f o r H I V / A I D S i n M y a n m a rUNAIDSparticipants in drug treatment provision.Twenty-five participants with backgroundsin psychiatry, social work, medicine andnursing attended the training, half of whomwere government staff.• WHO, with the NAP and the Department ofHealth’s Drug Abuse Control Project,organised a training workshop onAmphetamine-type Stimulants (ATS) with35 participants (clinicians) from the publichealth sector and NGOs, as well asrepresentatives from the CCDAC.Participants drafted a set ofrecommendations including advocacy forincreased access to treatment services andmore local research to better understandthe patterns of ATS drug use and theassociated HIV risk behaviours.Lessons learnt, as reported by partners working in HIV anddrug use.• Transparency, especially to local officials, is key to alleviating local fears andfacilitating project operation. For example, monthly meetings of harm reductionspecific Township Steering Committees, as well as monthly reports toauthorities, are reported as being key for facilitating operations and theenabling environment.• Continuous, sustained advocacy at all levels is crucial for projectimplementation. Although certain procedures remain sensitive, like provisionof sterile injection equipment and the integration of drug users in projectservice delivery, with continual transparency, advocacy and good planning, allcan be implemented.• Joint advocacy works better. One example, concerning the desire for increasedparticipation of drug users in programme design and implementation, partnerscollectively promoted the idea of a ‘needle patrol’, a team of former and currentdrug users attached to outreach activities with the task of collecting usedinjecting equipment from the assigned wards. It was found to be a lesssensitive way to integrate drug users in project implementation and had apositive impact in garnering community support.• Inclusion of the wider community, for example in health education sessionsor in provision of condoms and IEC materials, is effective for communitymobilization and community advocacy.• A ‘client matched’ model of outreach was used to gain access to hard-toreachpopulations, with a team of outreach workers selected from the samewards where they perform outreach activities.• A greater emphasis on drug treatment provision is needed, which in turnensures that drug users have greater support and opportunities to access adiversity of treatment options, with continuous support throughout treatmentand afterwards.• Peer education amongst injecting drug users has been a difficult area tonegotiate. Communities and authorities have resisted the involvement ofcurrent drug users in project activities. However, the Study Tour to Iran providedan example of how this dilemma can be overcome, by using peer educatorswho are receiving methadone.• In relation to authorities, despite many of the difficulties associated withimplementing activities, most of the positive developments in the HIV andDrug Use field have occurred with support from CCDAC.• Sufficient funding for referral activities and socio-economic support need tobe planned for programming in future.26

A n n u a l P r o g r e s s R e p o r t ,1 Apr 2006 - 31 Mar 2007Knowledge and attitudes improvedIncreased awareness of the modes oftransmission, means of preventing HIV,and perception of personal risk in thegeneral population, in three keypopulations at higher risk (sex workers,injecting drug users, men who have sexwith men) and among youth, were outputsof Component 3 of the Joint Programme.Activities also aim to improve attitudes inthe general population towards those livingwith or affected by HIV. Within theMyanmar National Strategic Plan on HIV,improvement of knowledge and attitudeshas now been integrated in each of theStrategic Directions aimed at each of thekey population groups. Accordingly, in thisreport, work with sex workers, clients, menwho have sex with men and drug usershas been discussed in the earlier sections.Other groups prioritized for intervention –like mobile populations and workers – arecovered here along with generalawareness efforts.Nineteen implementing partners funded bythe FHAM are working to improve theknowledge, perception of personal risk andattitudes towards HIV infection. Keyoutputs currently tracked include healtheducation sessions conducted, peereducators trained and involved inprogrammes, and people reached througheducation sessions.Peer education is a widely used strategyfor communicating behaviour changemessages, and UNAIDS facilitated areview on peer education in HIV projectsin Myanmar this year with the participationof FHAM implementing partners and otherstakeholders. 1Knowledge of modes of transmission, perception of personal risk and attitudesregarding HIV and AIDS improved among general populationFifteen implementing partners were working toincrease the knowledge of HIV in the generalpopulation. During the reporting period, 54,853sessions were held to deliver information on HIVfor the general population. Awareness raisingactivities conducted to reach the generalpopulation included World AIDS Day activities,festivals, competitions, public talks, videoshows, exhibitions and displays. A total of 1.3million pieces of IEC materials have beendistributed to the general population.1Copies of the final report “A review of Peer Education Approaches in the prevention of HIV in Myanmar” areavailable from UNAIDS office.27

F u n d f o r H I V / A I D S i n M y a n m a rUNAIDSPSI continued to produce and use televisionspots to reach the general population and thisyear aired messages on HIV prevention, HIVcounselling and testing, and non-discriminationagainst people living with HIV. In addition, 1,000mass awareness events were held, mostly videoshowings, using mobile video units transportedby truck or boat. The number decreased onthe previous year as some of the mobile unitswere withdrawn from service.The FHAM continued to support the workplaceprogrammes of the Myanmar Business Coalitionon AIDS (MBCA), PARTNERS, Malteser andthe NAP. MBCA had facilitated implementationof workplace HIV programmes in 43 privatesectorbusinesses in total by the end of theyear in seven townships in Pyay (Bago Division),Thandwe (Rakhine State), Kyaik Hto (MonState) and Yangon. Both MBCA andPARTNERS reported that it was harder to reachfactory workers than originally planned, as manyfactories in the main project areas had beenclosed since their projects were developed, andthat largely only workers in small-scaleindustries could be reached. Workplaces arevaried, including for example, construction sites,brick factories, garment factories, food and drinkprocessing, timber and furniture factories, busterminals, hotels and a naval academy. Peereducationhas been widely used as a strategyin the workplace with 796 peer educatorsinvolved at the end of the reporting period(MBCA, MHAA, NAP, PGK). Peer educatorsdelivered Behaviour Change Communication(BCC) sessions, often combined with condomdemonstration and distribution. Most factoriesdo not allow peer educators to hold sessionsduring working hours, and so there is onlylimited “private time” for health education. PyiGyi Khin provided health education sessionsand supported peer educators among seafarersand trishaw drivers. Malteser was able toaccess workers in rubber plantations in the WaSpecial Region. The Myanmar HealthAssistants Association (MHAA) received interimfunding from the FHAM for the last four monthsof the year to continue its peer educationactivities among seamen in Tanintharyi Division,initiated with Global Fund resources.28

A n n u a l P r o g r e s s R e p o r t ,1 Apr 2006 - 31 Mar 2007Awareness of HIV/AIDS among youth improvedApproximately 30% of the population ofMyanmar are youth of 15-24 years, and ninepartners implemented activities focusing onyounger people during the period. More than10,000 health education sessions wereconducted for in-school and out-of-school youth,reaching over 128,000 participants (chart 3.1).The projects of the Consortium and Save theChildren USA (SC-US) employed a life-skillstraining approach, within the framework ofadolescent reproductive health, primarily to outof-schoolyouth. Specific HIV-preventioneducation was delivered through small groupdiscussion, and youth peer educators providedinformation in youth-friendly drop-in centres. Inaddition, Marie Stopes International providedadolescent reproductive health and HIVinformation through drop-in centres establishedwith Global Fund resources and with interimsupport from FHAM for the seven months afterthat funding ended. The SC-US project inMagway made health education available to inschooland out-of-school youth, through peereducation and a drop-in Knowledge Centre. Themajority of youth were students in theuniversities and colleges in Magway, many ofwhom were living in hostels. Peer educatorswere able to reach fellow students with healtheducation in around 40% of the estimated 500hostels. The project also reached out-of-schoolyouth and trained peer educators from thispopulation, which included some sex workersand men who have sex with men. In addition,peer educators and volunteers from similar riskgroupsor backgrounds were organized into PeerSupport Networks, to provide mutual support.Community-based youth peer education wasthe focus of the Myanmar Red Cross Society(MRCS) FHAM project in the townships ofThaton (Mon State) Hpa-an and Kawkareik(Kayin State), where there is significant mobilityof young workers across the border intoThailand. UNODC provided information aboutHIV prevention and drugs in a demand-reductionstrategy in youth drop-in centres in its townshipsof implementation (Lashio, Tachileik, Muse). Anumber of structured recreational activities werealso provided through these centres. TheMyanmar Health Assistants Association starteda peer education project for youth in twotownships of eastern Yangon with Global Fund,and this was supported by the FHAM for fivemonths after funding stopped.In total, 539 youth peer educators were involvedin the FHAM-supported projects of MRCS, SC-US and UNODC at the end of March 2007,compared with 100 at the end of the previousreporting period (chart 3.2).Burnet Institute provided technical support andseed grants to the youth project of the MuslimCentral Fund Trust, to deliver HIV preventioninformation to Muslim young people throughpeers. Burnet also supported the Phaung DawOo Monastic Education High School inMandalay in an innovative approach to provideinformation on adolescent reproductive healthand HIV prevention in its curriculum. The projectwas reported to have stimulated a widerawareness and commitment to supportingpeople living with HIV in the local community.29

F u n d f o r H I V / A I D S i n M y a n m a rUNAIDSAccess to services for HIV care and support improvedExpanding coverage of quality care,treatment and support services for peopleliving with HIV is the goal of this component(Component 4 of the Joint Programme).This includes scaling up access toappropriate antiretroviral therapy (ART),treatment for AIDS-related infections, andcare and support in the community. Inaddition, it aims to increase coverage ofquality voluntary, confidential testing andcounselling (VCCT) and prevention ofmother to child transmission (PMCT)services.The outputs of this component mostlyrelate to Strategic Direction 11 of theMyanmar National Strategic Plan, Meetingneeds of people living with HIV forComprehensive Care, Support andTreatment, although services like VCCTcut across the other Strategic Directions.Quality and access to care and treatment services for people living with HIVimprovedService provisionThe number of persons receiving ART withsupport from the FHAM doubled in the twelvemonths to March 2007 to reach 6,116 persons(chart 4.1). ART is being provided through theprogrammes of five FHAM implementingpartners. Cotrimoxazole prophylaxis andtreatment for opportunistic infections haveincreased significantly this year (chart 4.2), withseven partners reporting against this coreindicator. The number of persons benefiting fromhome-based care has also continued toincrease steadily over this year through theprojects of six partners (chart 4.3). Careprovided to people affected by HIV has been ina range of forms: basic medical treatment,nutritional support for people living with HIV andtheir families, home-based care for patients withmobility difficulties, psychosocial support(including medical emergencies, hospital visits,child education support and funerals), andpalliative treatment and care for the terminallyill.The majority of people receiving ART are in MSF-Holland’s treatment programme (5,103persons). MSF-Holland uses multi-donor fundsto purchase ARV, and reports the total numberof persons on treatment, therefore the numberreported is not the number of treatmentsprovided with FHAM funding alone. MSF-Hollandreported that the geographical selection criteriafor ART patient recruitment were amended sothat more clinically eligible persons could beenrolled. In addition to ART, care, treatmentand support to people living with HIV alsoincluded prophylaxis and treatment ofopportunistic infections, psycho-social andnutritional support for clients and their families,home-based clinical care for immobile patients,and palliative care for the terminally ill. MSF-Holland also supported self-help groups forpeople living with HIV to provide a space toexchange experiences, for recreation, and tofacilitate greater involvement in the care andsupport of their peers.30

A n n u a l P r o g r e s s R e p o r t ,1 Apr 2006 - 31 Mar 2007The National AIDS Programme started ARTprovision in June 2005, and by 31 March 2007was providing treatment to 1,163 patients fromall funding sources (FHAM, Global Fund,Government of Thailand, International UnionAgainst Tuberculosis and Lung Disease). Ofthe total patients, 400 were FHAM-funded asof 31 March 2007, below the original FHAMtarget of 1,235. However, during 2006 theNational AIDS Programme added approximately470 additional ART patients (as of 31 March2007), supported by the brief phase-out packagefrom the Global Fund, which was prioritized forspending as it was less flexible than the FHAM.All FHAM funds allocated for the NationalProgramme’s ART were used on procurement,however, ensuring stocks for patients as supportis transitioned to the Three Diseases Fund incollaboration with WHO. WHO with NAP lastyear made nine monitoring visits to ART sites,and developed ART monitoring tools that recordclinical data and treatment adherence, whichare in use in all 13 public-sector ART sites. TheNAP provided over 14,000 treatments foropportunistic infections in this period, most ofwhich were made available in the secondsemester and reported in the third quarter ofthe year (chart 4.2), accounting for the peak inthe graph during that period.31

F u n d f o r H I V / A I D S i n M y a n m a rUNAIDSMSF-Switzerland is providing ART in Daweidistrict in Tanintharyi Division, and 501 patienttreatments were funded by the FHAM from atotal of 743 adults and 54 children receiving ARTat 31 March 2007. MSF-Switzerland reported1,743 HIV-positive clients enrolled and followedclinically through four clinics in Dawei district.Sixteen self-help groups were being supportedwith 340 members, and 39 peer educators hadbeen trained among people living with HIV.MSF-Switzerland also supports a group toprepare people living with HIV for ART treatmentadherence.32

A n n u a l P r o g r e s s R e p o r t ,1 Apr 2006 - 31 Mar 2007Chart 4.1AFXB was providing ART treatment for 70 clientsin collaboration with the Waibargi hospital inYangon. A delay was reported in reaching thistarget, as potential beneficiaries first had toundergo tuberculosis screening and treatment.AFXB has also focused on providing ARTreadinesseducation to people living with HIV.People living with HIV involved in self-help groupshave become aware of the benefits of ART butalso of side-effects, and as a result muchattention has been paid to the importance ofhealthy, positive living without ARV.During this period, 356 persons receivedCotrimoxazole prophylaxis, and 374 diagnosisand treatment of opportunistic infections.Tuberculosis treatment (DOTS) was beingprovided to 227 people living with HIV. Homebasedcare in the AFXB project includedmedical treatment for 526 people living with HIV,and psychosocial support though the self-helpnetwork for over three times as many people.These services were delivered through 30 trainedpeer educators, as well as members of the selfhelpgroups. The Alliance and the BurnetInstitute’s Centre for International Healthprovided capacity-building support to AFXB staff.Chart 4.233

F u n d f o r H I V / A I D S i n M y a n m a rUNAIDSAMI was able to initiate ART and followed 42persons in Dala township, Yangon Division,during this year, and 364 persons living withHIV were being followed clinically, including CD4monitoring, and receiving cotrimoxazoleprophylaxis. AMI plans to continue to add newART patients at a rate of 5 persons per monthto ensure close clinical follow-up. Home-basedcare was provided to 91 ill patients.The largest home-based care programme wasthat of the Consortium, reaching 4,900beneficiaries this year in 24 townships, andincluding nutritional support, counselling andreferral for treatment of illnesses. In townshipswith Myanmar Nurses Association participation,basic health care could also be provided in thehome. Many clients were also supportedthrough self-help groups.Pyi Gyi Khin (PGK) has been providing a homebasedcare package including treatment foropportunistic infections and counselling, to 451people living with HIV in Pathein and Myingyan,the two townships directly supported by itsFHAM Round II(b) project. FHAM monitoringvisits to both townships noted how PGKpartnered with NGO projects in the vicinity andwith NAP’s AIDS/STD teams to increaseaccess of project beneficiaries to services. Inaddition, PGK is providing home-based care inAungban township with FHAM supportchannelled through seed grants from the BurnetInstitute.The Alliance has supported its communitybasedorganisation partner projects in providinga range of care and support services dependingon the need and capacity of each individualorganisation. All projects provide home-basedcare services, which primarily involve provisionof basic medical and psychosocial support forpeople living with HIV and their families in theirhomes. This includes counselling, basic healthcare (oral rehydration salts, skin ointments,paracetamol), nutritional support, educationalsupport for children and information forprophylaxis and treatment of opportunisticinfections. The home-based care staff are alsotrained to recognise when patients should bereferred for medical care. The projects alsoprovide services in community centres such asgatherings of people living with HIV, vocationaltraining, clinical services and day care for preschoolchildren.Chart 4.334

A n n u a l P r o g r e s s R e p o r t ,1 Apr 2006 - 31 Mar 2007Capacity for implementationA second edition of the national ART clinicalguidelines for adolescents and adults and ARTpaediatric clinical guidelines were developed andrecently made available. The adult clinicalguidelines now include a chapter for specifictechnical issues on ART for injecting drug users,including concomitant methadone treatment.Specific considerations for pregnant women,updated protocols were also included for ARVprophylaxis in PMCT, patients with TB-HIV coinfectionand HIV and hepatitis-C co-infection.NAP organised one refresher-training on ARTfor 16 specialists, and two trainings onopportunistic infections for pathologists and labtechnicians. In addition, 200 basic health staffwere trained in ARV adherence counselling.During this year WHO, NAP and the MyanmarMedical Association together organised sixtraining sessions on ART management for 120general practitioners in Taunggyi, Yangon,Mandalay, Lashio and Tachileik. One trainingsession on CD4 lymphocyte countingtechnology was organised at the NationalHealth Laboratories in Yangon with theparticipation of 30 technicians from main referralART sites from the Ministry of Health and someNGO projects. This coincided with the arrivalin country of automated CD4-count machinesfrom other funding sources.The first workshop on continuum of care wasorganised by WHO and NAP in August 2006,with the participation of stakeholders fromgovernment and NGO sectors, facilitating thedefinition of packages of services and promotionof referral at township level. Mandalay, Monywaand Tachileik were identified as pilot locationsfor implementation of continuum of care. NAPofficials subsequently accompanied a groupincluding representatives of people living withHIV on a study tour to Chiang Mai, in whichparticipants could observe the continuum of careimplementation in Thailand.A national training of trainers on the MyanmarIntegrated Management of AIDS and otherIllness (MIMAI) was held in Yangon. IMAI is aset of simplified tools for delivering HIV-relatedhealth services – including increasing thenumber of care-related tasks taken by nursesand other basic health staff - adapted from thegeneric IMAI developed by WHO and beingused in several countries of Africa and Asia.Over a period of two weeks 20 doctors, 18nurses, 18 counsellors and 13 ‘expert patients’from different parts of Myanmar first trainedtogether for MIMAI. This first group of trainersis now a core that will support the improvementand scaling-up of HIV health services. Followingthis training a group of nine doctors fromcontinuum of care pilot townships participatedin a second study tour to Chiang Mai for furthertraining opportunities and to observe theintegration of IMAI activities in continuum of careat hospital and community level.WHO and the Alliance developed a booklet forinformation and education of people living withHIV on proper adherence to ART, and anotherto raise awareness of opportunistic infectionsand promote early treatment seeking. Peopleliving with HIV participated in the developmentof these booklets.During the reporting period, the Alliance andBurnet Institute both arranged training for NGOand CBO partners’ care-and-support projectsin subjects including counselling, home basedcare, stages of HIV-related illness, tuberculosisand its treatment, prevention of mother-to-childtransmission, treatment literacy, as well asmonitoring and evaluation.35

F u n d f o r H I V / A I D S i n M y a n m a rUNAIDSQuality of and access to voluntary confidential counselling and testing (VCCT)services improvedOver 77,000 individuals received HIV test resultsalong with post-test counselling during this year,more than double the previous year (chart 4.4).HIV testing has now been authorized throughthe projects of two INGOs. Eighteen FHAMpartners are providing VCCT, with servicesvarying from referral, to counselling pre- andpost-test, or with the full package includingtesting in-house.MSF-Holland provided over 24,000 HIV testresults and post-test counselling, and reportedthat the demand for VCCT services hadcontinued to grow this year. The reasonssuggested for the growth included increasedpromotion of the services offered in the clinicsby health educators, the increased possibilityof access to ART encouraged people to findout their HIV status, improved counsellingmotivated more people to accept testing, andthat MSF-Holland had focused on offering VCCTto key populations at higher risk of exposure toHIV.UNFPA supported the public health services toprovide HIV counselling and testing to pregnantwomen in antenatal care and for the preventionof parent-to-child transmission of HIV, and26,000 tests were performed this fiscal year(and reported in indicator Number of clientsreceiving HIV test results and post-testcounselling). UNFPA’s policy was to encourageinvolvement of male partners of pregnant womenand promote partner counselling and testing.Chart 4.436

A n n u a l P r o g r e s s R e p o r t ,1 Apr 2006 - 31 Mar 2007PSI reported good uptake of VCCT in its new“QC” counselling and testing centres (Yangonand Mandalay), and that over 6,000 clients hadbeen tested and counselled. The Consortiumreported that the number of clients receiving testresults and post-test counselling had doubledthis year, and that other organisations hadreferred clients to CARE for post-test counsellingand support. Malteser also continued to provideHIV testing and counselling through its clinic inPang Kham in the Wa Special Region.National VCCT guidelines were updated thisyear to include new chapters on VCCT for sexworkers and injecting drug users.WHO continued to provide support to the NAPand the NHL for the implementation of thenational External Quality Assessment Schemefor HIV antibody testing (NEQAS). Two roundswere organised this year and the network oflaboratories participating was expanded to 97,mainly from the public health sector but alsosome from the NGO sector. NEQAS wassupported through eight site visits this year bynational consultants to laboratories in Myitkyina,Mogaung, Waing Maw, Kalay, Falam, Hakha,Sittwe and Ponnakyun.Caring, protective and supportive environment improved for people living withor affected by HIVAlthough no FHAM core indicators wereestablished this output of the Joint Programme,activities aiming to improve the caring, protectiveand supportive environment for people affectedby HIV are intrinsic to the programmes of manyFHAM implementing partners, including theAlliance, AFXB, Burnet Institute, and theConsortium.AFXB has continued to support and develop theSunday Empowerment Groups, which areestablished self-help groups in Yangon andMawlamyaing (Mon State) to improve thesupportive environment for people living with HIV,their families, and affected children. AFXBplanned to facilitate the division of the two largegroups into smaller, local groups, but reportedthat to date this had proved challenging.The Alliance has been supporting local NGOsand CBOs to build capacity to provide care andsupport to people living with and affected byHIV. Through the projects of eight NGO/CBOpartners, more than 1,200 people living with HIVhave been reached. The Alliance has beensupporting the following partner projects:• Myanmar Council of Churches, toprovide support to people living with HIVin Yangon through a drop-in centre.Services at the centre include regularsupport meetings, counselling, healthtalks and basic health care. The groupconducts education sessions in thesurrounding community to increaseawareness on HIV and reduce stigmaand discrimination. The project aimsto reach people living with HIV in Insein,North Okkalapa and Hlaingthayartownships in Yangon.• Karuna in Pyay (Bago Division), toprovide counselling, basic medicalcare, home visits, nutritional supportand educational support for childrenaffected by AIDS. The project alsoaims to raise awareness about HIV inthe community including on the needfor understanding and compassiontowards people living with HIV.• AFXB, in Yangon and Mawlamyaing,to support the development of theSunday Empowerment Group. A CoreGroup has been established among itsmembers to manage the project, andvolunteers provide a bedside careprogramme and nutritional support tohospitalised people living with HIVwhose family members cannot care forthem.• Linn Yaung Chi, a support group inMandalay, by assisting members toprovide mutual support and buildsolidarity among the group. In addition,volunteers carry out home visits topeople living with HIV to provideindividual and family counselling andbedside care for hospitalisedbeneficiaries whose family members37

F u n d f o r H I V / A I D S i n M y a n m a rUNAIDSare not able to care for them on anextended basis.• Yadana Metta, in Yangon andMandalay, to establish a day-carecentre for medical care, counselling,meditation sessions, nutritionalsupport and a space for people livingwith HIV, and a home-based careprogramme and support for childrenaffected by AIDS (funding from otherdonors). Yadana Metta promotescompassion and aims to decreasestigma and discrimination towardspeople affected by HIV.• Healthy Living Helping Society, inYangon, to provide education on HIVand to explore broader social issuesthat affect HIV vulnerability among menwho have sex with men. Volunteersalso carry out home visits to providecounselling to people living with HIV.• YMCA, to implement an HIV project inMogaung (Kachin State) that assistspeople living with HIV to increase theirincomes by providing vocationaltraining and supporting theestablishment of small businesses.YMCA volunteers also carry out homevisits to provide counselling andpsychosocial support. The projectaims to raise community awareness oncare and compassion for people livingwith HIV.• Metta Kyaemone, to run a day carecentre to provide health and nutritionalsupport to adults and children affectedby AIDS in Kyaikami (Mon State). Daycare for children under five yearsensures that the children have at leastone proper meal a day. The projectsupports education of school-agedchildren through provision of schoolfees, supplies and extra after-hoursclasses. Support is provided to theparents and family members withshelter, food assistance and medicalcare.The Burnet Institute has been supporting NGOsand CBOs with seed grants and capacitybuilding, and the projects assisted for improvingthe supportive environment include:• Myanmar Red Cross Society’s projectin Thaton township (Mon State), to traincommunity volunteers to provide careand support, with linkages with localmedical services and creation of a selfhelpgroup. The group started raisingits own funds from within the communityto be self-supporting, an indication ofcommunity ownership.• Pyi Gyi Khin, to improving quality of lifefor people living with HIV in Aungban(Shan State). Although there was aninitial focus on sex workers, in laterstages PGK decided to extend to meetthe needs of other groups in the area.Support to children without parentalcare and other affected children weremaking increasing demands on theproject.As part of their community and home-basedcare work, the Consortium member CAREreports supporting twelve self-help groups, whichinclude income generation activities. Whileincome generating activities were still in anearly, learning phase, groups already reportedimproving attitudes and reduced stigma bymembers of the broader community where theyworked. People living with HIV and their familiesdemonstrated strong commitment to helpthemselves, without the need for hand-outs nordependence on organisations for support.Partners reported that the numbers of childrenaffected by AIDS and children orphaned by HIVwere increasing in many communities. It wasnoted that while basic nutritional and educationsupport is provided by projects, the socialissues faced by affected children need also tobe addressed. The Consortium has supportedestablishment of committees in the communityto support the most vulnerable children, and thequality of life of these children has beenenhanced. Children actively participate in playand psychosocial support activities.Committees have adopted income generationactivities, and it is important that the proceedsfrom the committees directly support thechildren. A number of committees are savingthe funds raised for the time when NGOs canno longer provide nutritional, educational orfinancial support to vulnerable children. TheCommittees have established linkages into thecommunity health and education systems foryounger children. However, it was noted thatfurther integration of services for vulnerableadolescents would be beneficial.38

A n n u a l P r o g r e s s R e p o r t ,1 Apr 2006 - 31 Mar 2007Risk of mother-to-child transmission of HIV reducedThe FHAM supported an increase in coverageof services for the prevention of mother to childtransmission of HIV (PMCT) during this period,largely through UNFPA’s programme. Inaddition, five state/division-level hospital-basedsites were established by the NAP’s directimplementation with FHAM resources. (Thesetownships will continue to receive support eitherfrom the Three Diseases Fund in collaborationwith UNFPA or from UNICEF). Inputs providedby all partners included training of staff involvedat all levels of service delivery, blood collectionsupplies, HIV tests, safe-delivery kits, materialsfor universal precautions, and antiretroviralprophylaxis (Nevirapine). All FHAM-supportedtownships are shown in the map below in blue,and townships with other support in yellow. Thelatter includes 30 supported by UNICEF and49 established with GFATM funding, which weredivided between UNICEF and UNFPA forcontinued support after the GFATM resourceswere no longer available. PMCT services aredelivered through two models: hospital-basedand community-based. Recently, the focusshifted towards scaling up hospital-basedservices, while maintaining establishedcommunity-based sites.UNFPA was able to report that among 45,000clients visiting antenatal care services in 2006,21,000 accepted pre-test counselling and HIVtesting, with 18,000 receiving post-testcounselling. Of women tested, 1.1% were HIVpositive, and around 60% of HIV-positive womenreceived Nevirapine at the time of delivery. Inaddition, 319 spouses accepted HIV testing, ofwhom 42 were found to be antibody positive.UNFPA reported that two of 14 children testedfor HIV antibodies at 18 months of age werepositive. UNFPA collaborated with the MyanmarMedical Association to inform medicalpractitioners and mobilise beneficiaries forPMCT in 10 townships. This year, UNFPAincluded provision of Cotrimoxazole prophylaxisfor HIV-positive mothers and children insupported townships.In March 2007, a review of the national PMCTprogramme was co-organized betweenstakeholders: UNFPA, UNICEF, WHO and theNAP. Three teams of reviewers visited tertiaryteaching hospitals, township hospitals, Maternaland Child Health Centres and Rural HealthCentres in Yangon, Mandalay, Pyin Oo Lwin,Monywa, Bago, Pathein, Nyaung Oo andTaungtwingyi. The teams met with seniorclinicians, AIDS/STD team leaders, laboratorystaff, doctors, midwives, NGO staff, people livingwith HIV, pregnant women and expectantfathers.Among the key findings, the review team notedthat, since beginning in 2001 the programmehas been expanded to cover 89 townships, and37 hospitals were involved in provision of PMCTservices by the end of 2006. It was reportedthat currently 76% of women attendingantenatal care services in those locations wereoffered VCCT of which 57% were tested for thepresence of HIV antibody. The rate of HIVpositivewomen in 2006 was 1.5%. The reviewhighlighted the high level of commitment showedby the Department of Health to this programmeand the good progress made, particularly inincreasing geographical coverage since 2001.The review also noted that the PMCT programmehas led to increased attendance at antenatalcare services for all women, and that this wouldbe a positive step towards improving maternalhealth. Challenges currently faced by theprogramme included the low uptake of ARVprophylaxis after testing, and the number ofwomen lost to follow-up, as well as the need forupdating of programme technical procedures.The need to strengthen primary preventionactivities was stressed, including theinvolvement of men. There should be furtherexpansion of VCCT services to reach not onlythe general population but also key populationsat higher risk groups of exposure. The reviewproposed prioritisation of locations wherebehavioural data show that populations are atgreatest risk, and also provided practical39

F u n d f o r H I V / A I D S i n M y a n m a rUNAIDSrecommendations in areas of HIV care andsupport, supply management and models ofservice delivery to enable scale-up whileensuring quality of services.PMCT services are also being provided throughthe projects of AMI, MSF-Holland and MSF-Switzerland, of whom MSF-Holland reported thelargest number of mother-baby pairs receivingARV prophylaxis through its network of 16clinics.40

A n n u a l P r o g r e s s R e p o r t ,1 Apr 2006 - 31 Mar 2007Fund ManagementProgrammatic and Financial MonitoringUNAIDS carried out the day-to-day monitoringof programmatic implementation, and the FHAMteam at UNAIDS secretariat comprised sevenstaff: Programme Coordinator, Planning andM&E Officer (both international positions),National Officer (a medical doctor), NationalOfficer (M&E), Finance Associate, DataAssistant, and Administrative Assistant.Each partner’s FHAM workplans and budgetswere the basis for programmatic monitoring ofprojects. Each implementing partner had atany time one single contract with UNDP, andone workplan with one associated budget. TheFHAM team at UNAIDS secretariat preparedresults-based technical and financial reportingformats every quarter, based on the agreedworkplans and budgets. These includedquarterly indicator targets and planned quarterlybudget. Reporting formats were sent toimplementing partners towards the end of eachquarter, and completed reports were due by theend of the following month.Reports were reviewed initially at UNAIDSsecretariat by one of the two technical NationalOfficers assigned as focal person to theimplementing partner. One national FinanceAssociate also reviewed all reports, andtechnical achievements and expenditure werecross-validated jointly by the Finance Associateand the technical focal person. The quarterlyreports and the associated review documentswere further analysed by the Planning and M&EOfficer, before being forwarded to the FHAMProgramme Coordinator for approval. Reportedachievements were cross-checked during fieldvisits to project sites. Queries arising at anystage of the monitoring process were revertedto the implementing partners, and revisedreports submitted as requested. Data from theapproved reports were consolidated into twoproject tracking databases, one for eachimplementing partner project, and another tomonitor progress against the set of FHAM CoreIndicators.When staff was satisfied that technical andfinancial reports were acceptable, arecommendation was made to the Chair of theFHAM Management Committee, whoauthorized UNDP to disburse the planned cashinstalments requested by the implementingpartner. In cases where the implementingpartner had a significant cash balance in hand,disbursements were postponed, usually untilthe following quarterly cycle. The aim was thateach implementing partner would have adequatecash in hand for two full quarters ofimplementation, in order to avoid cash-flowdifficulties. This was especially important forsmaller and national organisations, and hadbeen adopted since the start of Round II of theFHAM, as a result of lessons learned duringRound I.Fund utilisation was discussed with partners,and projects that under-performed weresupported in re-programming of workplans.Overall, the utilisation of allocated funds wassatisfactory (details in Annexe 1). Evenimplementing partners that had experienceddelays in starting activities in Rounds II and II(b)were on track to complete expenditure by theend of the fiscal year ending March 2006.In addition to the review described above,reporting was validated through regular fieldmonitoring visits to implementing partnerprojects. In the fiscal year 2006, UNAIDSFHAM team conducted 14 monitoring trips,covering 19 implementing partners in 21 differenttownships in four states and five divisions (table5.1). Monitoring visits included the opportunityto interview project beneficiaries, as well as fieldstaff.41

F u n d f o r H I V / A I D S i n M y a n m a rUNAIDSTable 5.1 FHAM monitoring visits in fiscal year 2006International organisations with a proven trackrecord procured their own supplies andcommodities, while all procurement for nationalorganisations was undertaken by a UnitedNations organisation. This was usually UNDP,although some supplies for partners working ininjecting drug use were procured by UNODCand WHO. In this fiscal year, the FHAMsupported one national and one internationalProcurement and Supply Management officer.These two positions worked across UNorganisations, and the duties of the staff wereto assist in the process of planning andmonitoring procurement and management ofmedical commodities procured with Global Fundand FHAM resources. In addition, it was theofficers’ specific duty to support the Departmentof Health and its National AIDS Programme inplanning and monitoring medical commodities.Financial oversight and management wasundertaken by UNDP. In line with the OperationalProcedures of the FHAM, an internationallyrecognised auditing firm conducts yearly auditsof the accounts of all implementing partners.UNDP again contracted KPMG to conduct anaudit for the fiscal year 2005 in May 2006. Theissues raised by the auditors have been sharedwith the implementing partners and all issueshave been addressed. The final audit, includingthe fiscal year 2006 and the month of April 2007,is now in process.The FHAM Management Committee is currentlypreparing an end-of-programme evaluation of theFHAM by external expert consultants, to beheld this year.42

A n n u a l P r o g r e s s R e p o r t ,1 Apr 2006 - 31 Mar 2007Financial Status and Utilisation of FundsThe total donor contribution disbursed to UNDPand allocated to programmes amounted to USD26.9 million at the end of the fiscal year 2006(table 5.2). USD 24.9 million were allocated toimplementing partner projects, and a furtherUSD 2 million to monitoring and evaluation, andfund management. Implementing partnerexpenditures have seen a steady rise over timesince the beginning of the FHAM in March 2003to reach USD 9.35 million in fiscal year 2006(chart 5.3).In September 2006, the Expanded ThemeGroup decided that any unspent funds remainingat the end of the FHAM would be transferred tothe Three Diseases Fund. At the time of writing,it is estimated that this will amount toapproximately USD 150,000.Table 5.2 Donor contributions to the FHAM FY 2003-2006Chart 5.3Procurement of health products for NationalAIDS Programme was planned to allowstaggered deliveries and ensure optimal shelflifeof medical commodities. The twoProcurement and Supply Management officersfacilitated this process. However, whilecontracts for procurement of supplies had beenentered into in advance, the staggered deliveryof consignments, with payment due only ondelivery, meant that not all obligations had beenrecorded as expenditure by the end of March2007. This included a substantial amount ofhigh-value anti-retroviral medicines and HIV testkits and explains the expenditure status of theNAP at 30 April 2007 (Annexe 1).43

F u n d f o r H I V / A I D S i n M y a n m a rUNAIDSOperating EnvironmentDuring 2006, partners were able to implementactivities to achieve significant results, asdetailed throughout this report. The Ministry ofHealth facilitated functioning of partners throughthe continued implementation, renewal orestablishment of Memorandums ofUnderstanding, and assisted with obtaining ofvisas, travel permissions and facilitating importof commodities. Partners nevertheless facedoperational obstacles that slowedimplementation or inhibited rapid expansion.Obtaining visas and travel permissions remainsa lengthy process, taking several weeks in bothcases. Access is not permitted to someimportant areas for HIV prevention work, suchas Mong Shu in Southern Shan state andtownships on the border with Thailand.The Ministry of Health established a newMemorandum of Understanding with the AsianHarm Reduction Network, which had previouslyworked with the Ministry of Home Affairs. Thetransfer of MoU took some time to finalize butwill now allow for the expansion of harmreduction activities into new townships.However, the reduction of involvement by theMinistry of Home Affairs in issues related toHIV represents a step backwards with respectto the multi-sectorality of the response. TheMinistry of Home Affairs, with its responsibilitiesto manage the police and township generaladministration, has significant influence over theenvironment for the implementation of HIVprevention activities. At least three partners,for example, reported increased ‘crack-downs’and arrests of sex workers, seriously hinderingthe efficacy of outreach and peer educationprogrammes.Other aspects of the controlled environment inMyanmar can also result in programmeinefficiencies. Community organizations needpermission to undertake activities, which cantake months to obtain. Without an efficientregistration process providing a basis forcommunity organizations to function, each andevery activity requires approval. Some localauthorities still prohibit group training in thecommunity, requiring many repeated sessionsof few individuals.At the same time, the capacity of the Ministryof Health itself remains a constraint. Increasedhuman resources would improve its ability tocoordinate and facilitate the work of multiplepartners. The fact that the Ministry of Health’scentral staff are in Nay Pyi Taw while mostpartners are in Yangon has resulted in increasedtime spent travelling and reduced the efficiencyand opportunities for meeting, collaboration, andinformation exchange.Last year, the Government issued newguidelines to the international community –United Nations organisations and NGOs alike– for the coordination and registration oforganisations undertaking humanitarian work.In turn, the United Nations communicated tothe Government the humanitarian principles thatit and associated humanitarian organizationsfollow for the implementation of their activities(see Annexe). During 2006, the guidelines didnot appear to present large problems toimplementing partners, who were able toimplement their activities largely in line with thestated humanitarian principles. FHAM partnerresources were not diverted from programmebudgets nor were recruitment processeshindered, for example. Partners did report anincreased number of requests for the sharing ofinformation at the township level.44

A n n u a l P r o g r e s s R e p o r t ,1 Apr 2006 - 31 Mar 2007Annexe 1: Implementing Partners expenditure and budgetsFHAM Round II+IIb Implementing Partners, including April lump-sum extension45

F u n d f o r H I V / A I D S i n M y a n m a rUNAIDSFHAM Round II+IIb Monitoring and Evaluation ComponentNote: The UNAIDS FHAM budget was amendedand contract extended to the end of July 2007to ensure that the FHAM programme unit isable to complete final reporting of the FHAM.Partners completed implementation by 30 April,and were obliged to make final technical andfinancial reports by 15 June. The UNAIDSFHAM unit was to process final technical,financial and annual reports, and wrap-up theFHAM in the six-week period to the end of July.46

A n n u a l P r o g r e s s R e p o r t ,1 Apr 2006 - 31 Mar 2007Portfolio of FHAM Rd I, II & II(b) and Implementing Partner Budgets47

F u n d f o r H I V / A I D S i n M y a n m a rUNAIDS48

A n n u a l P r o g r e s s R e p o r t ,1 Apr 2006 - 31 Mar 2007Annexe 2: Summary of Technical Progress Apr 2004–Mar 2007Yearly Achieved and Total 01 April 2004 to 31 March 200749

F u n d f o r H I V / A I D S i n M y a n m a rUNAIDSAnnexe 3: Achievements by Implementing Partners Round II, II(b)1. Access to services to prevent the sexual transmission of HIV improved (JP Component 1)50

A n n u a l P r o g r e s s R e p o r t ,1 Apr 2006 - 31 Mar 20072. Access to services to prevent transmission of HIV in injecting drug usersimproved (JP Component 2)51

F u n d f o r H I V / A I D S i n M y a n m a rUNAIDS3. Knowledge and attitudes improved (JP Component 3)52

A n n u a l P r o g r e s s R e p o r t ,1 Apr 2006 - 31 Mar 20074. Access to services for HIV care and support improved (JP Component 4)53

F u n d f o r H I V / A I D S i n M y a n m a rUNAIDS5. Enabling environment: Policy development, advocacy, capacity building and research (JP Component 5)54

A n n u a l P r o g r e s s R e p o r t ,1 Apr 2006 - 31 Mar 2007Manuals and Guidelines developedAMITools for use in the project:• STI flowchart• Clinical management of PLHA• PMCT guideline• VCCT guideline• Referral protocol• PEP procedu res• Counselling guideline for PLHA (Pre-ART and Treatment Adherence counselling)• STI counselling guidelineBI-CHR• The Harm Reduction Operations manual was completed• Three fact sheets:o Methadoneo Supply, Demand and Harm Reductiono Amphetamine Type Stimulants• Policy and Procedures manual and a user’s guide to the MIS database manual• All materials apart from the user’s guide to the MIS database were completed in Englishand in Myanmar languageBI-CIH• A poster series on basic elements of providing home-based care for care-givers wasdeveloped for partner LNGOS, and covered key elements of care.Consortium• Treatment flowcharts for STD syndromes for STI service providers including generalpractitioners• Booklets on STI treatment guidelines for STD syndromes for service providers includinggeneral practitioners• General and STI counselling books for service providers and field workers• Pamphlets for STI and VCCT• Life Skills Handbook (abridged version of the life skills concepts)• Consortium Strategy (inclusive of Minimum Service Provision Standards)• Consortium Performance Management Framework (M&E, Quality Assurance)Alliance• Developed a number of modules for peer education on prevention of HIV among men whohave sex with men, sex workers and people living with HIV.• A curriculum for training on treatment literacy for people living with HIV was developedwith WHO for use by project partners.• Translated and adapted a document 115 ways to energise groups: Games to use inworkshops, meetings and the community, a resource for use in participatory workshops.MBCA• Counselling guidelines.55

F u n d f o r H I V / A I D S i n M y a n m a rUNAIDSNAP• PEP guidelines• Manual on HIV prevention for Basic Health Staff• Drug adherence counselling guidelinesSC-US• M & E Manual• M & E Tool Guide• PE/PC Training Manual• Life Skills handbook• Counselling Check List• Youth Friendly Service Provider Agreement• PDQ Manual and Guideline (Translation to Myanmar)• Youth Action Kit (Translation to Myanmar)• Guideline for Multi-Sectoral Task ForceUNFPA• VCCT guidelinesWHO• Guidelines for the clinical management of HIV infection in adults and adolescents, SecondEdition, 2007• Guidelines for the clinical management of HIV in children in Myanmar, Second Edition2007• National Standard Treatment Guidelines for the Management of Sexually TransmittedInfections in Myanmar. 2007• Flow-Charts Syndromic Management of Sexually Transmitted Infections. 2007• Practical Handbook National Treatment Guidelines for the Management of SexuallyTransmitted Infections in Myanmar. 2007• Guidelines for Primary Health Care Services for Injecting Drug Users, Myanmar September200656

A n n u a l P r o g r e s s R e p o r t ,1 Apr 2006 - 31 Mar 2007Annexe 4: Guiding principles for the provision of humanitarianassistanceI. Objectives and focus of humanitarian assistance1. Human suffering should be addressed wherever it is found, with particular attention to themost vulnerable in the population such as children, women and elderly. The dignity andrights of all must be respected and protected.2. Humanitarian assistance is to be provided without engaging in hostilities or taking sidesin controversies of a political, religious or ideological nature. There will be no weapons orarmed personnel on the premises or transportation facilities of humanitarian organizations.3. Humanitarian assistance is to be provided without discriminating on grounds of ethnicorigin, social status, gender, nationality, political opinions, race or religion. Relief ofsuffering must be guided solely by needs and priority is to be given to the most urgent ofcases of distress.4. Humanitarian assistance aims to help reduce poverty, meet basic needs and enablecommunities to become more self-sufficient.5. Humanitarian activities are guided by international humanitarian law and human rightsand by the mandates given by international instruments to the various humanitarianorganizations.II.Management and operational principles6. Humanitarian actors respect the culture, structures and customs of the communitieswhere humanitarian programmes are carried out. Where possible and to the extentfeasible, ways shall be found to involve the intended beneficiaries of humanitarianassistance and/or local personnel in the design, management and implementation ofassistance programmes.7. Humanitarian agencies hold themselves accountable to those they seek to assist andwill be accountable for their actions to the government, and for their use of resources, tothose who provide them. Humanitarian actors retain responsibility to manage human,financial and material resources for their activities. Management of these resourcesfollows transparent, independent, open, competitive processes. Specifically, staff arerecruited on the basis of suitability and qualifications for the job.8. Equipment, supplies and facilities of humanitarian actors are not to be used for purposesother than those stated in programme objectives. Vehicles of humanitarian agencies arenot to be used to transport persons or goods that have no direct connection with assistanceprogrammes.9. Humanitarian assistance is only of value if delivered in a timely fashion. Effectivehumanitarian operations require unhindered, sustained access for humanitarian personnelparticipating in relief activities to deliver, monitor and assess humanitarian aid, enablingthem to reach targeted members of the population in need of assistance.57

F u n d f o r H I V / A I D S i n M y a n m a rUNAIDSAcronyms and abbreviationsFHAM/Joint Programme Implementing PartnersAFXBAssociation François Xavier BagnoudAHRNAsia Harm Reduction NetworkAMIAide Médicale InternationalARHPAsian Regional HIV/AIDS ProjectBI-CHR Burnet Institute Centre for Harm ReductionBI-CIHBurnet Institute Centre for International HealthCCDAC Central Committee for Drug Abuse Control; Ministry of Home AffairsConsortium Myanmar NGO Consortium (5 member NGOs below)CARECARE InternationalMNAMyanmar Nurses AssociationMSIMarie Stopes InternationalSC-UK Save the Children-UKWVIWorld Vision InternationalDEPTDepartment of Education, Planning and TrainingFHAMFund for HIV/AIDS in MyanmarAlliance International HIV/AIDS AllianceLOPLashio Outreach Project (UNODC)Malteser Malteser InternationalMANAMyanmar Anti-Narcotics AssociationMBCAMyanmar Business Coalition on AIDSMdMMédecins du MondeMRCSMyanmar Red Cross SocietyMRTMinistry of Rail TransportationMSF-CH MSF-SwitzerlandMSF-H MSF-Holland (AZG)NAPNational AIDS Programme, Dept. of Health; Ministry of HealthPARTNERS Partners NGOPGKPyi Gyi KhinPSIPopulation Services InternationalSC-US Save the Children-USAUNAIDS Joint United Nations Programme on HIV/AIDSUNDPUnited Nations Development ProgrammeUNICEF United Nations Children’s FundUNFPA United Nations Population FundUNODC United Nations Office on Drugs and CrimeWHOWorld Health OrganizationOther acronymsARTAnti-Retroviral TherapyARVAnti-Retroviral(s)BCCBehaviour Change CommunicationBSSBehavioural Surveillance SurveySWSex Worker(s)ETGUnited Nations Expanded Theme Group on AIDSFYFinancial YearIDUInjecting Drug User(s)IECInformation, Education, CommunicationIPImplementing PartnerJPJoint Programme for HIV/AIDS in MyanmarM&EMonitoring and EvaluationPLHIVPerson(s) Living with HIVPMCTPrevention of Mother to Child TransmissionSTISexually Transmitted Infection(s)TCPTargeted Condom PromotionVCCTVoluntary, Confidential Counselling and Testing58