Case Study Linking young men who have sex with men with sexual and reproductive health and HIV services: peer education in Myanmar
p2 Linking young men who have sex with men with sexual and reproductive health and HIV services: peer education in Myanmar About the International HIV/AIDS Alliance We are an innovative alliance of nationally based, independent, civil society organisations united by our vision of a world without AIDS. We are committed to joint action, working with communities through local, national and global action on HIV, health and human rights. Our actions are guided by our values: the lives of all human beings are of equal value, and everyone has the right to access the HIV information and services they need for a healthy life. About Link Up Link Up, an ambitious five-country project that ran from 2013-2016, improved the sexual and reproductive health and rights (SRHR) of nearly 940,000 young people most affected by HIV in Bangladesh, Burundi, Ethiopia, Myanmar and Uganda. Launched in 2013 by a consortium of partners led by the International HIV/AIDS Alliance, Link Up strengthened the integration of HIV and SRHR programmes and service delivery. It focused specifically on young men who have sex with men, sex workers, people who use drugs, transgender people, and young women and men living with HIV. International HIV/AIDS Alliance 91-101 Davigdor Road Hove, East Sussex BN3 1RE United Kingdom Tel: +44 1273 718 900 Fax: +44 1273 718 901 Email: mail@aidsalliance.org Registered charity number 1038860 www.aidsalliance.org For more information visit www.link-up.org Acknowledgements Written by Yamin Shwesin, reviewed by Felicia Wong and edited by Sarah Hyde We would like to thank the Government of the Netherlands for funding the Link Up project. International HIV/AIDS Alliance, 2016 Information contained in this publication may be freely reproduced, published or otherwise used for non-profit purposes without permission from the International HIV/AIDS Alliance. However, the International HIV/AIDS Alliance requests that it be cited as the source of the information. Designed by: Jane Shepherd/Garry Robson Unless otherwise stated, the appearance of individuals in this publication gives no indication of either sexuality or HIV status. Cover photo: Handing out condoms. 2016 International HIV/AIDS Alliance in Myanmar
Linking young men who have sex with men with sexual and reproductive health and HIV services: peer education in Myanmar p3 Executive summary In Myanmar, young people are in urgent need of sexual and reproductive health (SRH) and HIV information, education and services. Men who have sex with men (MSM) experience widespread stigma and discrimination. Young MSM have to conceal their sexual orientation, face particular barriers in accessing SRH and HIV services and information, and are often more vulnerable to HIV and sexually transmitted infections (STIs) than other young people or older MSM. To fill this gap, Alliance Myanmar, with Link Up support, has collaborated with local community-based organisations in empowering young MSM. Working through peer educators, who, as MSM, are the key agents of change, Link Up has succeeded in reaching young MSM. Link Up has informed young MSM of their sexual and reproductive health and rights (SRHR), provided information about HIV and SRH, offered crucial support, and referred them to youth-friendly service providers for tailored, integrated services. 1. Context In Myanmar, HIV prevalence among men who have sex with men (MSM is 6.6%. 1 The highest prevalence was reported among MSM aged 35-39; prevalence among young people aged 15-24 was estimated at 3.8%. According to the 2012 national progress report, HIV prevention services were delivered to 68,067 MSM out of a total population of 240,000: illustrating the need to reach more MSM across the country. Almost 82% of MSM reported using a condom the last time they had anal sex with a male partner. Just over a quarter - 27% - of MSM have tested for HIV. 2 Despite high levels of reported condom use, socio-cultural norms and taboos around same-sex relationships restrict MSM s access to essential SRH services and information. Younger MSM in Myanmar are at higher risk because most of the interventions are not youth-friendly. Young people are in need of information and education about SRHR and HIV as well as life skills and communication skills. What s more, young MSM are reluctant to seek sexual health messages and services out of fear of disclosing their sexual orientation to others. Older MSM, especially rich and famous people, pursue young boys, sometimes offering money or gifts: resulting in young MSM becoming sex workers. In Myanmar culture, MSM even experience stigma and discrimination within the family. Some service providers have discriminatory attitudes towards MSM: this serves as a barrier to MSM accessing services. A study by the Burnet Institute and the Population Council highlighted the risk to MSM in carrying condoms, due to fears of family and friends judging them. 3 1 Ministry of Health (2015), Myanmar - global AIDS response progress report - 2015. 2 Integrated biological and behavioural surveillance survey (2009), cited in the global AIDS response progress report. 3 Population Council and Burnet Institute (2015), Sexual health and HIV risk behaviours of men who have sex with men in Myanmar - baseline findings from Link Up. Link Up study brief. Available at: http://www.popcouncil.org/uploads/pdfs/2015hiv_ MyanmarBaseline_StudyBrief.pdf
p4 Linking young men who have sex with men with sexual and reproductive health and HIV services: peer education in Myanmar 2. About Link Up In Myanmar, the Link Up project is implemented with community-based organisations The Help, Ever Green Lover, Lotus, Khine Hnin Si, Lump light, Kyittaya Swe Taw Oo, Rays of Light Mee Aein Shin Lay Myar to reach MSM aged 10-24. MSM peer educators were recruited by CBOs and trained by the Alliance Myanmar to provide individual and group health education, promotion and counselling on SRHR, HIV, sexuality and sexual violence. Peer educators refer young MSM to youth-friendly service providers so that they can access tailored SRH and HIV services. I met a young MSM sex worker while I was going for a health education session. He was afraid of others finding out his sexual orientation and sex worker status. But he told me frankly what happened to him because we are peers. I explained about sexually transmitted infections (STIs) and HIV. I was able to send him to the clinic where they tested, diagnosed and treated his genital ulcer. (MSM peer educator, Yangon) The qualitative findings of the study conducted by the Burnet institute and Population Council to evaluate the acceptability and effectiveness of the Link Up project highlighted MSM s positive interactions with peer educators. The study found that participants were happy with the health education provided by the peer educators, and that they were an approachable resource. Participants also valued the role that peer educators could play in helping them to access clinic services, and appreciated the support offered. We usually meet each other at night, when we are looking for our partners, sometimes we meet them [peer educators] on the street, or during group discussions. If we are interested in a blood test [referral for an HIV test], peer educators accompany us to the clinic - that s what I appreciate the most: feeling like we are not alone. (MSM participant, Burnet Institute/Population Council study) The programme has built strong links with other local organisations and the government National AIDS Programme (NAP). CBO staff and volunteers have developed effective communication and coordination skills with NAP and service providers, in order to link young MSM with SRH and HIV services.
Linking young men who have sex with men with sexual and reproductive health and HIV services: peer education in Myanmar p5 I was introduced to a Khine Hnin Si (MSM CBO) peer educator. He explained the ways in which HIV is transmitted and asked me to go for testing and counselling. When I tested and the result was positive, they referred me to the clinic, and helped me to get antiretroviral therapy (ART). After getting ART, they also provided nutritional support for me. Now I am feeling well, and he [the peer educator] comes to see me regularly. (Young MSM, Monywar) Myanmar outreach workers in Yangon. 2016 International HIV/AIDS Alliance in Myanmar 3. Strategies Link Up has identified a number of good practices, including: Sensitise the community to reduce stigma and discrimination towards MSM and extend access to services: Link Up staff and volunteers regularly conducted meetings to sensitise people with some influence over MSM, such as parents, teachers, carers, local authority and senior staff in partner organisations. During the meetings, the SRH and HIV needs of MSM were outlined. Link Up staff also explained the importance of community acceptance and participation in enabling MSM to reduce their vulnerability to HIV and STIs and increase access to SRH and HIV services. These sensitisation meetings succeeded to some extent in fostering acceptance of MSM, for example, some parents allowed their sons to receive health education sessions and services. Facilitate group meetings to engage young people in Link Up activities: The involvement and participation of young people who are most affected by HIV - was boosted through group meetings. These meetings enabled
p6 Linking young men who have sex with men with sexual and reproductive health and HIV services: peer education in Myanmar young key populations from districts, who otherwise would have been underrepresented, to participate and speak up about the issues that concerned them. During group meetings, young people were informed of SRH, HIV, and their right to access services. They were told that they could be referred to youthfriendly health facilities for services. Young people who participated in group meetings provided feedback and suggestions regarding Link Up activities and information, education and communication materials. Youth who took part in group meetings showed a willingness to be involved in project activities. They also passed on what they had learnt to their friends and referred them for SRH and HIV services. Use online media to reach hidden populations: Alliance Myanmar runs a Facebook page where young people can post questions about HIV, STIs, ART, SRH services and other related issues. Designated Alliance staff members respond to the questions. On average, they receive about ten questions per week. Some of the Link Up volunteers use social media to reach out to hidden young key populations who conceal their sexual orientation. Young people can talk to peer educators online where they can share their feelings, discuss their behaviour, and receive SRH and HIV information. Peer educators provide counselling to foster behaviour change and persuade young MSM to undergo HIV testing. Young people are informed that they can choose which youth-friendly service provider they visit and that the SRH and HIV services will be free of charge. As a result of peer educators skills in building trust and communicating, hidden youth who are more vulnerable to HIV met peer educators face-to-face, tested for HIV and requested SRH services. A mentoring training session for youth advocates by Link Up project. The project set up and supported a network of youth advocates working towards enabling legal and policy environments for young key populations. 2016 International HIV/AIDS Alliance in Myanmar
Linking young men who have sex with men with sexual and reproductive health and HIV services: peer education in Myanmar p7 Empower young key populations to lead youth in SRHR and HIV: Peer educators who conduct health education and referral services were recruited from young key populations who understand the key issues affecting youth. Alliance staff and the partner organisations supervisors trained the peer educators in SRHR, HIV, sexual orientation and identity, and effective communication. Some of the peer educators became youth advocates. They were empowered to advocate to various influential people on behalf of young key populations SRHR and HIV needs. Youth advocates met with parliamentarians and championed young key populations SRH and HIV needs, priorities and rights. Build staff and volunteers capacity to carry out monitoring and evaluation: Link Up staff and volunteers were empowered to strengthen their technical and management skills through training, mentoring and supervision. Link Up introduced the SyrEx database for use in data management and reporting at field level. Staff and volunteers responsible for M&E and reporting also attended computer training courses, in line with the Link Up staff capacity building plan. The central M&E unit provided training and close supervision of the computerised reporting system. The timeliness, accuracy and comprehensiveness of partners reports improved during the three-year project period. Previously, we used a paper-based system for reporting where we did not know if the client codes were double counted or not when we had a heavy case load. All the manual checks, aggregations and calculations meant that finishing the reports in time was a challenge. Now we can use the SyrEx database to check the double counting of client codes and we can easily cross-reference the database with the registers before the reporting deadline. Sunday Empowerment Group staff member 4. Results By the end of the three-year project period, Link Up: trained 35 peer educators provided SRH and HIV services for 26,363 MSM aged 10-24, of whom nearly a third (32%) were aged 10-19 provided STI diagnosis and treatment for 1,106 MSM provided HIV testing and counselling for 4,463 MSM.
p8 Linking young men who have sex with men with sexual and reproductive health and HIV services: peer education in Myanmar 5. Challenges Challenges encountered include: Cultural attitudes towards condoms and discussing sex: Parents and carers think that talking about sex and condoms promotes sexual activity among young people. Some parents and carers did not want condoms to be discussed with their children. Condoms may fuel stigma as they are perceived to encourage young people to have sex. Reaching MSM at higher risk: The behaviour of some MSM such as young men who sell sex puts them at higher risk of HIV and STIs. Volunteers faced difficulties in locating them to convey SRHR and HIV messages as the nature of their work is mobile and they do not openly admit that they are working as sex workers. One of the Link Up peer educators shared his experience of working with young MSM sex workers, They do not always use condoms if the customer offers extra money and it s tricky to meet them to provide health education. Parents assume that their sons are still children, but, in reality, they are having sex. Attitudes towards condoms are a barrier to young people s health education. The community needs more sex education. Lotus staff member member Accessibility of services at a convenient time: Link Up activities were planned to reach vulnerable youth in various settings. Staff and volunteers conducted health education sessions in the garment industry where young people were employed as factory workers. Youth at risk of HIV were referred for HIV testing and counselling and other SRH services, as needed. Most of the service providers work during the week, however, the garment industry employees are only free on Sunday. The limited availability of services at the weekend poses a significant problem for young people who want to know their HIV status and access SRH services. Morning Beauty Routine: This transgender lady runs a beauty parlour in Yangon. She lives with her partner and has been with him for 5 years. 2016 International HIV/AIDS Alliance in Myanmar
Linking young men who have sex with men with sexual and reproductive health and HIV services: peer education in Myanmar p9 6. Lessons learnt Some of the doctors from general practitioner clinics are still influenced by cultural norms and are not familiar with key populations. MSM who were not satisfied with the service offered at a clinic due to the service provider s manner may tell others about the doctor s attitude, which could lead to other MSM feeling reluctant to visit that clinic and obtain services. Link Up therefore informs young key populations that they can choose service providers who have been specifically trained in how to deliver services to young key populations. Programme staff reviewed the service providers according to feedback from volunteers and beneficiaries, and referred young key populations to non-judgemental service providers. 7. Sustainability beyond Link Up Link Up staff and volunteers have established a relationship built on trust with the young key population community after three years of implementing the project. Although the project is over, young key populations still ask staff and volunteers for advice regarding SRHR and HIV, and referrals for services. KTV pimps and managers ask for condoms to be made available in their brothels and KTVs. They also invite peer educators to offer health education. Teachers and community leaders still invite peer educators to come and give SRHR and HIV information. This shows that Link Up has had a lasting impact on the community: empowering them to demand the SRHR and HIV information and services they urgently need. Sharing about the Link Up project with meeting participant. 2016 International HIV/AIDS Alliance in Myanmar
p10 Linking young men who have sex with men with sexual and reproductive health and HIV services: peer education in Myanmar 8. Contact details International HIV/AIDS Alliance in Myanmar No.24, 2nd Street, Hlaing Yadanamon Housing. Hlaing Township, Yangon Division, Myanmar. Telephone: +0095-1-537 342, 500 619, 525715.
Linking young men who have sex with men with sexual and reproductive health and HIV services: peer education in Myanmar p11 Clients at a parlour are getting dressed up for their graduation. 2016 International HIV/AIDS Alliance in Myanmar
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