Chapter II

The Role of Non Governmental Organizations in HIV/AIDS Prevention in Myanmar

Introduction

Prevention efforts to control HIV spread are crucial for reducing prevalence rates and require a
collaborative approach involving government, partners, and various sectors. Initially, few NGOs in Myanmar
had HIV programs, focusing on awareness and condom distribution. Post-1995, some INGOs and UN
organizations, like UNICEF and WHO, began prevention efforts and advocacy. WHO provided training, while
UNDP supported local organizations with condom promotion, test kits, and educational materials. HIV
transmission occurs via bodily fluids, with sexual transmission being the predominant mode. In 2011, 65% of
HIV infections were due to heterosexual transmission, 26% to injecting drug use, and 5% to contaminated
blood. With rising infections in 2020, increasing awareness and urgent action by practitioners and policymakers
is essential. This chapter include prevention of three main modes HIV/AIDS transmission, mother to child,
injecting drug use and sexual transmission.

Prevention of Mother to Child Transmission (PMTCT)

Beyond sexual transmission and injecting drug use, HIV transmission from parent to child is common in high-
prevalence areas. In Myanmar, the 2011 data from the Ministry of Health and Sports estimated 72,000 females and 8,000
children living with HIV. About 8,000 HIV-positive mothers required antiretroviral (ARV) prophylaxis to prevent
mother-to-child transmission.1 The high number of HIV-positive mothers underscores the need for enhanced prevention
efforts. Without intervention, infants born to these mothers are at risk of HIV infection, impacting their health and well-
being.

Preventing HIV and AIDS among reproductive-age individuals and focusing on prevention of mother-
to-child transmission (PMTCT) was a key strategic goal in Myanmar’s National Strategic Plan (NSP) for 2016-
2020. 2Early HIV testing for pregnant and breastfeeding women, especially those at higher risk, and safe index
testing for their partners and children are essential. Pregnant individuals with HIV should receive antiretroviral
therapy (ART) throughout pregnancy and childbirth to prevent perinatal transmission of HIV. ART involves a
combination of HIV medications to manage the virus.

In 2011, 3,003 pregnant women received PMTCT services from government and NGOs in Myanmar. Of
these, 2,097 received a two-drug combination, and 906 were on ARV treatment during delivery. 3There were no
reports of single-dose Nevirapine (NVP) treatment. Out of 1,191 identified HIV-positive women delivering at
program sites, 1,091 (92%) received NVP prophylaxis.

1
Harms, Gundel, Angelika Mayer and Heiko Karcher; Prevention of Mother – to – Child Transmission of HIV, International
Coordination Office GTZ PMTCT, Berlin, Germany, September 2013,123
2
Review of Myanmar NAP ,2011,56
3
PMCT in Myanmar
 UNICEF prioritized PMTCT to meet UNGASS goals, including improving maternal and child health
services. Assessments in Tachileik and Kawthaung, high-infection areas, led to recommendations for pilot
PMTCT interventions focusing on primary prevention, voluntary counseling and testing (VCT), ART for
pregnant women and newborns, and improving postnatal care. The community-based PMTCT program, started
in 2011 and expanded to include hospital-based services in 2014, is growing at 5-10 townships per year. By
2018, 315,920 women received pre-test counseling, 178,000 were tested, and 1,300 mother-child pairs received
preventive ARV.

MMCWA, collaborating with MoH and UNFPA, provides maternal and child care, focusing on reducing
mortality and promoting safe motherhood. They also conduct training for community health workers and
housewives to support HIV prevention and PMTCT. 4Despite progress, Myanmar’s PMTCT program faces
challenges, including funding gaps and policy constraints. However, by the end of 2019, the program covered
99% of townships. In 2019, 90% of pregnant women received pre-test counseling, 89% were tested, and 88%
received post-test counseling, showing significant progress. The HIV-positive rate among pregnant women was
stable at around 0.5%, with 95% of identified HIV-positive women receiving prophylaxis or treatment. The
program is on track to achieve its eMTCT goals.

The public sector is the main provider of PMCT services through collaboration with the Maternal and
child health program. Union has been supporting the NAP in implementing the PMTCT program. Moreover,
the NAP has been collaborating with some community-based organizations and ethnic group organizations to
provide PMTCT services in hard-to-reach areas. Other organizations such as MSF-Holland provided ANC
services only to their existing cohort of HIV-positive patients and also in collaboration with the NAP. The
public sector was providing PMTCT services in 326 of 330 townships (99% coverage) and at 38 PMCT
hospitals across the country by the end of 2019 with the following (Table 1). 5This high PMTCT coverage is the
major first step in the path to eMTCT.
Table (1) : National AIDS Program PMTCT sites (2011–2019)
Year Number of Community based Number of Hospital based
PMCT sites PMCT sites
2011 235 38
2012 253 38
2013 256 38
2014 267 38
2015 301 38
2016 308 38
2017 319 38
2018 321 38
2019 326 38

4
UNGASS Country Progress Report 2018,23
5
Myanmar Progress Report ,2019,45
Source – Myanmar Progress Report 2019

Significant progress was made in 2019, 74% of HIV-exposed infants received ARV prophylaxis, with 40% getting co-
trimoxazole prophylaxis and 53% undergoing a virological test within two months of birth. This achievement marked significant
progress toward the eMTCT target. 6From 2011 to 2020, access to ART for pregnant women improved, significantly reducing new
HIV infections among children from 1,200 in 2011 to 600 in 2020, thanks to PMTCT programs. PMTCT programs were implemented
nationwide with support from NGOs like NAP, Union, and MSF-Holland, which trained healthcare workers and raised awareness.
However, challenges such as stigma and inadequate funding have hindered progress. Many pregnant women fear stigma, leading to
missed opportunities for early diagnosis and treatment. Additionally, funding gaps persist despite efforts to secure international
support.

Prevention of HIV Infection among Injecting Drug Users(IDUs)

In some ASEAN countries such as Thailand, Myanmar, and Vietnam, HIV epidemics have been documented among injecting
drug users (IDUs) due to sharing equipment. In Myanmar, efforts to reduce new infections among people who inject drugs (PWID)
have been intensified, particularly in areas where opium production is prevalent. 7 Injecting drug use is both urban and rural, posing
challenges for geographical coverage of prevention interventions, especially in rural, mining, and border areas with large PWID
populations.

In 2011, there were an estimated 16,000 IDUs in Myanmar with a 25% HIV prevalence, amounting to around 4,000 HIV-
infected IDUs. The Myanmar Health and Development Consortium (MHDC) launched the first NGO intervention in 2005, focusing
on harm reduction through needle exchange programs, HIV testing, counseling, and antiretroviral therapy. Under the Global Fund and
with support from international and national NGOs and the Central Committee for Drug Abuse Control (CCDAC), primary health
care services linked with drug treatment services were provided. However, IDUs faced exclusion from policy planning due to legal
barriers, stigma, and their hidden status. Joint program activities aimed to improve their involvement in planning and implementation.

The Global Fund and the 3DF significantly contributed to HIV prevention among IDUs by funding needle exchange programs,
opioid substitution therapy, and outreach services. As a result, HIV prevalence among IDUs decreased from 31% in 2011 to 15% in
2020, thanks to these harm reduction programs. NGOs like the Myanmar Drug Users Network (MDUN) and the Myanmar Positive
Group (MPG) have been vital in providing support, reducing stigma, and advocating for policy changes. They have implemented
needle and syringe distribution programs through organizations such as the Myanmar Red Cross Society and Population Services
International (PSI).

Comprehensive harm reduction programs are active in states with high injecting drug use prevalence: Kachin, Mandalay,
Sagaing, and Shan North. However, Shan State, with its high prevalence of HIV/AIDS among IDUs, faces challenges due to its drug
trafficking links, poverty, and limited healthcare access. 8Since 2017, harm reduction interventions, including methadone programs,
have ceased in Yangon, leading to a significant drop in comprehensive HIV prevention services.

Due to the funding cut from the Global Fund, fewer organizations are working in the area of harm reduction than in 2018. In
2019, eight organizations AHRN, MAM, MANA, MdM, Metta, DDTRU, NAP, SARA were working with the Drug Dependency
Treatment and Research Unit (DDTRU) solely on providing methadone maintenance therapy (MMT). Three organizations received
additional funding from the USAID HIV/AIDS Flagship Project (UHF) to focus on harm reduction.

6
“Zafrin Chowdhury; Trend of HIV in Myanmar: Women Emerge as the New Face of the Epidemic posing Children at High
Risk,” UNICEF Myanmar Newsletter, Volume 4, No.1, Yangon, UNICEF Myanmar, March 2018.
7
The ASEAN Work Programme on HIV/AIDS (2012-2015), Jakarta, ASEAN Secretariat, 2002
8
Three Disease Fund: Newsletter, Issue-1, Yangon, 3DF, December 2018-January 2019
 Prevention services for people who inject drugs (PWID) have been increasing in momentum since the start of National
Strategic Plan III.9 In 2011, number of PWID reached by specific services were estimated 20,000 (10%) to increase estimated 50,000
(24%).It was because a drop in prevention reach while maintaining the HIV testing numbers .For PWID, the same calculation method
as for FSW and MSM is used to compensate for possible double counting within and among organizations.

In 2019, around 55,000 PWID in Myanmar received HIV prevention services, covering 59% of the estimated PWID
population. The main organizations, AHRN and MANA, achieved 78% of the prevention reach. HIV testing and post-test counseling
were provided to 86% of those reached, with a 24% HIV positivity rate among tested individuals. Although needle and syringe
distribution exceeded targets, other prevention indicators fell short.

The needle and syringe program expanded significantly, distributing over 35 million syringes in 2019, nearly doubling since
2015. This was an average of 351 syringes per PWID, surpassing the global recommendation. However, distribution was uneven
across regions, with high concentrations in Kachin and Shan North but reduced in Sagaing, Shan East, Shan South, and
Yangon.NGOs conducted outreach and harm reduction activities, including education, syringe distribution, and counseling. In
Yangon, townships like Hlaing Tharyar, North Okkalapa, and Dagon Seikkan received extensive outreach and methadone
maintenance therapy (MMT) services. NGOs like MDPAG and MANA played key roles in these efforts.

MMT programs, started in 2005, have expanded significantly, with over 100 clinics by 2020. These clinics have been crucial
in addressing opioid addiction. Despite progress, challenges such as limited funding, stigma, and the COVID-19 pandemic continue to
impact service delivery. NGOs have been pivotal in reducing HIV prevalence among IDUs from 35% in 2011 to 15% in 2020.
Continued support and investment are essential to sustain and expand these efforts and address remaining challenges.

Prevention of Sexual Transmission

A key factor in HIV transmission in Myanmar was the lack of condom use in commercial sex. In 2011, an estimated 3,564
female sex workers (FSWs) and 4,320 MSM were living with HIV. To combat this, many countries focused on increasing condom
use through education and distribution. Since the early 1990s, NAP, NGOs, and UN agencies have promoted condom use through
health talks and distribution.10 PSI was a major player in condom distribution. The 100% Condom Use Programme (100% CUP),
successful in countries like Thailand and Cambodia, was adopted in Myanmar in March 2011, starting in four pilot townships:
Kawthaung, Tachileik, Bago, and Pyay.

By March 2012, a technical forum on 100% TCP led to the program’s expansion: 14 townships in 2012, 57 in 2013, 110 in
2014, and 154 in 2015, reaching 170 townships by 2018. PSI supported condom access through social marketing, and the targeted
outreach program (TOP) launched in 2014 aimed at reducing HIV transmission among MSM and FSWs, supported by USAID,
UNFPA, 3DF, and the Bill and Melinda Gates Foundation.

In 2014, approximately 10 million condoms were distributed for free, while PSI’s social marketing network distributed 70% of
the 35 million condoms reported. By 2014, retail outlets purchasing condoms from PSI grew from 1,400 in 2000 to 10,000, covering
nearly all 324 townships in Myanmar. 11In 2015, UNAIDS estimated 40 million condoms distributed, with 6.7 million by NAP and the
rest through PSI’s social marketing. PSI was the largest distributor, followed by MSI among INGOs, and MRCS and MMA among
NNGOs. In 2018, MANA distributed 172,438 condoms with 3DF funding.

Condom distribution peaked at 49 million in 2016 but dropped in 2017 due to changes in PSI’s policy and reduced NAP
funding. Although distribution increased in 2018, it remained affected by funding issues and Global Fund withdraw. In 2017, twelve
9
Dr.Mya Oo; HIV/AIDS Strategies and Achievements in Myanmar
10
WHO, UNODC, UNAIDS technical guide for countries to set targets for universal access to HIV prevention,
Treatment and care for injecting drug users 2012. Available from https://www.who.int/publications/i/Item/978924150437
11
Joint Programme for HIV/AIDS in Myanmar Progress Report 2014-2015,34
organizations reached 39,180 MSM, with PSI reaching 77% of them. 12 The HIV Sentinel Survey found a 29% HIV-positive rate
among MSM, highlighting the need for expanded services. In 2018, MSM made up 29.3% of HIV infections. Services for MSM
included behavior change communication, STI prevention and treatment, and confidential counseling.

Despite some progress, gaps remain in prevention services. NSP III aims to enhance HIV testing and treatment. In 2019,
nearly 90% of FSWs reported condom use with their last client, indicating successful behavior change. 13 An estimated 84% of FSWs
received prevention services, with 80% tested for HIV. Yangon, Mandalay, and Kachin saw the highest FSW reach, while Rakhine
saw notable improvement despite conflict. For MSM, 2019 IBBS showed reduced condom use and testing rates, with 66,428 MSM
reached after adjusting for double counting.

Prevention reach among MSM has been fluctuating during this decade, while the HIV testing figure has been increasing along
the way. The numbers reached by prevention and the numbers tested were similar in 2019. In 2019, the same nine organizations
Alliance, IOM, Malteser, MAM, MdM, MSI, NAP, PGK, PSI, PUI as in 2018 continued to provide HIV prevention services for
MSM, reaching more than 87,000 MSM in total . Considering double counting, with the same reason and calculation method
mentioned above for FSW, the final adjusted figure became 66,428 .

At the national level,49% of reachable MSM were covered by HIV prevention programs and 47% by HIV testing services
(HTS) in 2019, marking improvements in both areas. HIV-positive test results have been gradually decreasing since 2017 as testing
coverage increased.14 Prevention services were offered to MSM in 15 of 17 states and regions, excluding Chin and Kayah due to low
key population numbers. Most states saw increased MSM reach, except Kayin, Mon, Shan (S), and Tanintharyi, with Rakhine
showing notable progress due to collaboration between community networks and NAP. Yangon had the highest MSM reach, followed
by Mandalay, Ayeyawady, Bago, Sagaing, and Kachin. Kachin had the highest coverage at 84%, with other regions like Ayeyarwady
and Tanintharyi at 62%, while coverage in Kayin was under 20%.

In 2019, over 42 million condoms were distributed, with 78% through free distribution, targeting key populations. PSI was the
largest distributor, providing 78% of services, while four INGOs contributed 14%. Continued concerted efforts from government and
NGOs have significantly reduced HIV/AIDS rates among FSW and MSM in Myanmar from 2011 to 2020. 15However, ongoing focus
on high-risk populations and evidence-based interventions is crucial for further progress. Additionally, preventing HIV among drug
users and their partners remains a key area for action.

Conclusion

In conclusion, most NGOs engaged in distributing Information, Education, and Communication (IEC) materials and delivering
educational talks. Major NGOs like MMCWA and MRCS were particularly effective in public outreach. The SHAPE program, a
government initiative with UN collaboration, was the primary awareness campaign, while other programs were led by NGOs. Despite
efforts by NAP and NGOs such as Burnet, Alliance, and MMA to enhance capacity through training, the implementation of the
National Strategic Plan remained essential. Progress in Myanmar included increased access to HIV prevention services, notably
condoms, with PSI leading distribution efforts. However, condom distribution declined in 2017 due to reduced PSI activity and
funding issues. INGOs like CARE, MDM, and MSF-H distributed free condoms, and PSI was a major provider for MSM prevention
activities. Harm reduction initiatives for drug users expanded annually. INGOs had varied roles: Burnet focused on capacity building,
AHRN on needle distribution, CARE on NSP with psychosocial support, and MDM on NSP and IDU healthcare. MSF-H was the
largest needle and syringe distributor, while MANA, though limited in distribution, had more DIC centers. PMCT programs, a
12
Habib Rahman, Cameron Wolf and Marc Theuss; All MSM Are Not the Same: Adapting behavior change communication to the
needs of MSM subpopulations in Myanmar, at http://www.psi.org
13
National Strategic Plan on HIV/AIDS 2016-2020 (NSP III), National AIDS Program, Ministry of Health and Sports, Myanmar
14
Integrated Biological and Behavioural surveillance among female sex workers and men who have sex with men (2019
preliminary results), Ministry of Health and Sports, Myanmar.
15
collaboration involving NAP, AMI, MSF-H, MMCWA, UNFPA, and UNICEF, showed progress but fell short of UNGASS targets.
MMCWA faced funding challenges due to perceptions of being a government-linked NGO. Effective HIV prevention requires strong
leadership to drive

community involvement and secure investments. The National Strategic Plan 2016-2020 aimed to enhance government leadership and
encourage multi-stakeholder participation in HIV/AIDS prevention, care, and treatment.