Wednesday, December 18, 2013

Myanmar’s ‘Big Sister’ Leads in HIV Fight

An organization formed by sex workers for sex workers is making strides in reducing the rate of infections

Myanmar may have grabbed the world’s eye by opening its borders and ushering in a foreign investment surge, but one story has slipped quietly under the radar. The country has also significantly reduced the rate of HIV infections in its sex worker population from its previous high of 40 percent in females 2005, according to Population Services International (PSI) down to less than 10 percent today.

“Myanmar allowed sex worker-run programs to organize and scale up over the last eight years using an empowerment-based model, rather than a coercive testing model like the 100 percent condom programs in Thailand and Cambodia. The success of the program in reducing HIV rates so dramatically shows investing in sex worker-run programming works,” Andrew Hunter, program and policy manager of the Asia Pacific Network of Sex Workers (APNSW), told The Diplomat.

Myanmar’s HIV epidemic paralleled Cambodia’s, which peaked at over 42 percent for brothel-based workers and 18 percent for entertainment workers a decade ago, according to the National Center for HIV/AIDS, Dermatology, STD (NCHADS), but its peer-led outreach did so with far less media attention and international NGO fanfare.

Not Smothered by INGOs

Melissa Hope Ditmore, one of the foremost researchers on worker-led initiatives in the sex industry, documented a case study of Targeted Outreach Program (TOP), the largest HIV prevention program in Myanmar initiated by PSI. The project has been unique for reaching up to 55 percent of female sex workers and 70 percent of MSM out of the country’s estimated 60,000 sex workers. From NYC, Ditmore told The Diplomat “TOP was very successful working against HIV and STIs. We know that community-lead initiatives are the most effective.” 

Kay Thi Win started working in 2004 with TOP in peer education after being approached by them while employed as a sex worker. It was a job she came to from economic hardship after her father died in 1998, while she was studying at high school. Win’s mother could not support the family and they lost their home. In 2000, a friend introduced her to sex work as a way to support her family. Initially she told them she was working at a factory near the Thai border, but now they know about her work and support her. According to Raks Thai, an NGO that helps migrant workers, reports that migrants from Myanmar comprise the largest groups of all migrants in Thailand due to limited work options, but Win preferred to stay in the country.

She learned about the HIV epidemic sweeping the country from TOP and how to use condoms for protection. Win told The Diplomat from a conference on HIV in Bangkok that by 2012 the rate of HIV had declined to just 7.1 for sex workers. Though no longer working for TOP, she still refers sex workers to the project for health services.

Win now heads the AIDS Myanmar Association (AMA). AMA is Burmese for “big sister.”  Win says that AMA is the only 100 percent sex worker-led organization in the country.AMA does health education, referral health services for HIV, and STI counseling and treatment. [There is] sexual and reproductive health treatment, also for our members who are getting sick,” said Win.
Ditmore explained “Sex workers have since started a project that they direct, rather than being a subsidiary of another project. I expect that if AMA continues its work, which is lead by sex workers, that it will have great success and boost the reach of existing services to which they refer others.”

AMA’s work has also caught the eye of the Association of Women’s Rights in Development (AWID), the “only international feminist membership organization.” Win was invited to speak to AWID in the beginning of 2012 and surprised the organization by saying that sex workers do not see themselves as victims in need of rescue but are rather the empowered one in the financial transaction. She now sits on AWID’s board as the first sex worker to do so in its history.

Staying Safe in Sex Work

The feminist group awarded AMA a grant for teaching financial skills to sex workers. “We believe that sex workers earn a lot of income but do not know to how to save their money,” Win explained. “AMA advocates with bank staff and managers to provide training for sex workers [on the] banking system and information about bank savings.” Win adds, “Many of sex workers do not have a National Identity card,” which she says is needed to open a savings account.

Win thinks women working in entertainment clubs like beer gardens and karaoke clubs (KTV) make “around $100 to $200 money per month from drinking and pocket money (tips), with the salary.” Though no exact data is reported, a large number of people live on $2 or less a day in Myanmar (49 percent of Cambodians do so), so this is a large sum of money.

“The first job is to be an entertainer and they are paid about $30 a month, then they can be a sex worker. We also have ‘beer girls’ [beer sellers]. They sell beer in a bar, but they don’t have to drink beer. They are paid about $70 a month, but if they sell more beer, they get a percentage of that. A ‘bar girl’ [a term used to describe women who provide company to men visiting the bar] gets a salary of around $50 to $80 a month.” Bar girls and beer sellers are also common in Cambodia.

“We also have karaoke and night club workers. If a sex worker gets a drink at the club, she gets a percentage of the drink. If the client gets a session at karaoke, he will often drink with her and she can [get a percentage} of that as well. Massage workers don’t drink.”

Win notes that the clients are mostly locals. “There are far fewer foreign men.” Of the foreigners, most are Asian businessmen. “Sometimes local customers give more [money] than foreigners.”

 “We have condoms in brothels, massage places and KTV, but some of the KTV and massage owners or managers do not want us to take them but we try to keep them with girls and do advocacy toward that.”  Win says that “unofficially” condoms are used as evidence by police to arrest sex workers but they are not used to prosecute them in court.

Street-based workers comprise the majority of AMA’s members at about 70 percent. Win says rather than being the “poorer option,” some choose this over club work, preferring to be more independent. “In Myanmar sex workers from different cities and ethnicities, but [there are more] Burmese. We have a significant number of male, transgender sex workers and bisexuals.”

AMA is also supported by Myanmar Health and Development Consortium (MHDC) through a grant from UNFPA. The UNFPA and UNDP are working with AMA on a report on violence against sex workers. Dr. Hla Hla Aye, UNFPA Assistant Representative, Myanmar Country Office explained in an email to The Diplomat: “The decline of the HIV epidemic in Myanmar is due to the coordinated efforts of all stakeholders and national leadership with support from the UN and other actors together with community empowerment…however, the prevalence is still high in IDU [injecting drug users], SWs, and key affected populations still face the risk of stigma and discrimination, but to a much lesser degree compared to ten years back.”

U.N. affiliate Global Commission on HIV and the Law recommended in their report HIV and the Law that sex work be decriminalized to improve the global HIV response, an initiative that APNSW, the regional sex worker network wholly supports. 

Tracey Tully, Advocacy & Communications Officer for APNSW, told The DiplomatWe argue in favor of full decriminalization of sex work, because sex workers have the right to work with other people. Sex workers have the right to work with cleaners, receptionists, administrative staff, security personnel, drivers and sex workers have the right to work for establishments, to have bosses. To put it simply: ‘If my boss is criminalized, I cannot use condoms.’  Any form of criminalization will have a detrimental effect on sex workers’ ability to negotiate safe sex and on community’s ability to respond effectively to the HIV epidemic.”  

Antiretroviral Therapy Drugs (ARV) in Myanmar

Access to treatment for HIV positive people in Myanmar is a major problem, especially for people in rural areas. It affects not only sex workers but also migrants living in Thailand.
 “We would say that access to Antiretroviral Therapy drugs (ARV) is still a challenge for Myanmar however, a decentralization program for ARV has been initiated to overcome access problems,” noted Dr. Hla Hla Aye of the UNFPA.

AMA is proactive here as well, providing ARV to its members and a place (an apartment) for them to stay in Yangon while getting medicine “because people need to stay a minimum of two weeks to a month,” said Win.

While AMA has found a way to help its members, HIV positive migrants face treatment obstacles. Brahm Press of Raks Thai Foundation told The Diplomat they are highly mobile group and separated from their networks at home, so tend to seek out sexual companionship. Though a survey identified the use of sex workers’ services without condoms as a path of transmission for Burmese fishermen, Press clarified that these tend to be “sweetheart” relationships. Because of the perceived level of intimacy, condoms were not used. “Serial monogamy without condoms has been identified as a path of HIV infection.”

Unlike Myanmar, Thailand has national health insurance with access to ARV, but migrants may not necessarily be able afford it. Press said “Just recently the Thai government announced a change in the general health insurance for migrants. They raised the price to 2,200 baht a year, plus another 600 for the health examination, annually. This new rate includes ART and, supposedly, all migrants, regardless of documentation status can subscribe. The catch is, the government estimates they need 300,000 migrants to enroll to break even. There is inconsistent implementation of the policy with a number of hospitals not announcing the new policy; and at some locations, migrants living with HIV who bought health insurance prior to the announcement of the new policy were told that they still need to buy ARV out of pocket and cannot buy into the new insurance until their old one expires. With a lack of access to ART, some are advised to return to Myanmar, which has access problems itself.”

Press explained that even though migrants may find treatment at home, eventually they will want to return. “[Migrants] come from rural areas and there are still not enough jobs in their home countries. So, even if they do go home to start treatment, they will most likely return to Thailand once they are strong, to continue working. And that raises other concerns about adherence.”
Though solutions are being worked on for those needing ARV treatment in Myanmar and Thailand, the means to economically support oneself while on treatment appears to be another obstacle in resolving Myanmar’s HIV situation.

Ditmore reported that programs like TOP prioritize hiring sex workers who are HIV positive for peer education, but limited job openings will likely be an issue for sex workers – who often also come from rural areas – at least until Myanmar’s economy becomes stronger.
Michelle Tolson is a freelance journalist based in Asia.

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