Community engagement for improved outcomes for HIV/AIDS in Myanmar

HIV Australia | Vol. 12 No. 2 | July 2014

By Dr Paul McShane

A program to strengthen the HIV/ AIDS response in Myanmar was recently undertaken by Monash University under the Australian Government’s Australia Awards Fellowships (AAF) program.

Twenty senior health professionals from Myanmar’s Ministry of Health, Universities and non-government organisations (NGOs) such as the United Nations (UN) World Food Program and Marie Stopes International, worked with Monash academics to explore community engagement strategies for addressing HIV/AIDS and maternal health in Myanmar.

Monash brought interdisciplinary insights including contemporary biomedical approaches to community health care and the participants from Myanmar brought knowledge and experience of the social and cultural context in which the HIV/ AIDS epidemic is being tackled in their country. There are clear mutual benefits in such programs.

Total expenditure on health in Myanmar remains low at about 2% of GDP, compared to Australia’s 9.5% of GDP.¹ Out-of-pocket expenditure on health ranks among the highest in the world and accounted for 92% of all health expenditure in 2010.²

Thus, typically, it is the poor who lack effective access to health care. Rates of HIV infection in Myanmar are among the highest in South East Asia.

Myanmar’s epidemic is concentrated in select risk groups, including sex workers and their clients, men who have sex with men, people who inject drugs and the sexual partners of these groups.^{3 4}

In dealing with the HIV epidemic, Myanmar has developed a National Strategic Plan on HIV and AIDS. Although comprehensive and well-targeted, there remains difficulty in financing this plan,⁵which has already entered its second phase.⁶

The plan is coordinated by the Ministry of Health and is overseen by a Technical and Strategy Group on AIDS comprising representatives of donors, NGOs, UN agencies and the government.⁷

This reflects the multi-sector approach to funding and ongoing efforts of international agencies. The Monash AAF program emphasised community-level approaches and sought to complement these multisectoral efforts directed at health care in Myanmar through engagement with key practitioners and their representative agencies.

The Monash Fellowship program focused on primary health care through proactive community engagement rather than on clinical intervention. It addressed the first strategic priority of the National Strategic Plan: prevention of the transmission of HIV through unsafe behaviour.

An interdisciplinary program

The program was necessarily interdisciplinary, recognising that community engagement for improved health outcomes requires understanding of the cultural, ethnic, religious, social and legal context in which behaviour affecting the health of individuals is influenced.

Social support networks through communities are key vehicles to transfer relevant information and knowledge to develop understanding of disease prevention strategies among vulnerable groups and the community at large.^{8 9 10}

Such issues are well understood, for example in the African contexts cited above, but cultural influences on health-related behaviour in Myanmar are not well described in the literature.

Interactive intercountry programs, such as the Monash AAF program, offer opportunities for solutions to current health problems to be developed in a culturally relevant interdisciplinary environment.

Having a mix of government and NGO representatives assisted in bringing realistic and candid perspectives on cultural and social drivers of behaviour and on practical cost effective intervention strategies.

An open and interactive environment with facilitated discussion sessions helped with constructive information exchange.

Criminalisation creates vulnerability

In Myanmar, sex work, homosexuality and use of injection drugs – all prominent modes of HIV transmission in Myanmar – are currently illegal.

This not only influences behaviour, for example by discouraging individuals from seeking advice or treatment from government health agencies, but criminalises many social interactions, influences power structures and creates inequality, particularly among women. Female sex workers lack power in enforcing the use of a condom by their clients.

Acting outside the law, sex workers are vulnerable to HIV infection and other sexually transmissible infections (STIs), and also to violence and other anti-social behaviour.¹¹

Male workers from Myanmar migrating temporarily to Thailand or China for employment can acquire HIV through local sex workers and then pass the virus on to their partners back home.

Continuing poverty reduction efforts will assist in reducing economic incentives for sex work and migration, and help reduce gender inequality.

De-stigmatisation of gay men along with community leadership on social justice will also encourage access of vulnerable groups to necessary health services.

Prominent Myanmar pro-democracy politician and Nobel Peace Prize Laureate, Aung San Suu Kyi, is the UNAIDS Global Advocate for Zero Discrimination and therefore a powerful ally in the battle against HIV-related stigma.

With relatively few trained health professionals available, particularly in regional areas of Myanmar, there is a reliance on informal health services.¹²

Community health workers and volunteer health workers play important roles, engaging members of the community and influencing behaviour both positively and negatively.¹³¹⁴

In some cases, traditional norms may be inconsistent with necessary interventions. In particular, linking evidence-based approaches to community health to the traditional care-giving provided by community health workers is vital to improving health outcomes.

Capacity development

Developing capacity among community health workers who understand customary norms and cultural drivers of behaviour formed a critical component of the Monash program.

This strategy represents a conduit for promoting the importance of incorporating evidence-based approaches to primary health care, awareness-raising among the community harnessing trusted relationships, and adoption of practices which prevent HIV infection among community members.

The Monash program enabled an exploration of evidence-based approaches to HIV prevention and primary health care in Myanmar with the participants’ knowledge and understanding of the cultural, ethnic, social and political landscape as a vital background.

There is now a team of highly motivated health professionals back in Myanmar ready to further improve the response to HIV/AIDS, and strong personal and institutional relationships between Australia and Myanmar to draw on in the future.

Acknowledgements

Funding support through the Australian Government’s Department of Foreign Affairs and Trade through the Australia Awards Fellowships (AAF) program is gratefully acknowledged. Comments and suggestions by Dr Miranda Smith, Dr Tina Kalivas, and by participants in the AAF program were gratefully received.

Dr Paul McShane is Chief Research Officer at the Monash Sustainability Institute, Monash University

References

1 Australian Institute of Health and Welfare (AIHW). (2013). Health expenditure Australia 2011–12. Health and welfare expenditure series 50. Cat. no. HWE 59. AIHW, Canberra.

2 Saw, Y., Win, K., Shiao, L., Thandar, M., Amiya, R., Shibanuma, A., et al. (2013). Taking stock of Myanmar’s progress toward the health-related Millennium Development Goals: current roadblocks, paths ahead. International Journal for Equity in Health, 12, 78.

3 Auerbach, J., Parkhurst, J., Caceres, C. (2011). Addressing social drivers of HIV/AIDS for the long-term response: conceptual and methodological considerations. Global Public Health, 6, suppl 3, S293–S309. doi: 10.1080/17441692.2011.594451

4 Bergenstrom, A., Abdul-Quader, A. (2010). Injection drug use, HIV and the current response in selected low-income and middle-income countries. AIDS, 24, s20– s29.

5 Saw, Y., et al., (2013), op. cit.

6 Myanmar National Strategic Plan and Operational Plan on HIV and AIDS 2011–2015, available at: http://www.nationalplanningcycles.org

7 ibid.

8 Airhihenbuwa, C., Obregon, R. (2000). A critical assessment of Theories/Models used in health communication for HIV/ AIDS. Journal of Health Communication, 5, 5–15.

9 Airhihenbuwa, C., De Witt Webster, J. (2004). Culture and African contexts of HIV/AIDS prevention, care and support. Journal of Social Aspects of HIV/AIDS Research Alliance, 1, 4–13.

10 Auerbach, J., et al., (2011), op. cit.

11 Talikowski, L., Gillieatt, S. (2005). Female sex work in Yangon. Sexual Health, 2(3), 193–202.

12 Tin, N., Lwin, S., Kyaing, N., Htay, T., Grundy, J., Skold, M., O’Connell, T., Nirupam, S. (2009). An approach to health system strengthening in the Union of Myanmar. Health Policy, 95(2–3), 95–102.

13 ibid.

14 Thomas-Slayter, B., and Fisher, W. (2011). Social capital and AIDS-resilient communities: strengthening the AIDS response. Global Public Health, 6, S323–S343. doi: 10.1080/17441692.2011.617380.