Joint UNFPA/WHO Meeting on 100% Condom Use Programme, Manila, Philippines, 3-5 October 2006 : report

WPRO FILE (REPORTS OF MEETINGS)

Joint UNFPA/WHO Meeting on 100°/o Condom Use Programme

Manila, Philippines 3-5 October 2006

(lZ?f ~) World Health ~ Organization - ..--.:--

Western Pacific Region

W 0/~RO Ll.H '1\.f ila. PhihPPin

(WP)HSVICPIHIVIl.4/001 Report series number: RSI2006/GE/26(PHL)

English only

REPORT JOINT UNFPA I WHO MEETING ON 100% CONDOM USE PROGRAMME

Convened by: UNITED NATIONS POPULATION FUND WORLD HEALTH ORGANIZATION (REGIONAL OFFICES FOR SOUTH-EAST ASIA AND THE WESTERN PACIFIC) Manila, Philippines 3- 5 October 2006

Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines Deeember 2006

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NOTE

The views expressed in this report are those of the participants in the Jo~nt UNFPA/WHO Meeting on 100% Condom Use Programme and do not necessanly reflect the policies of the Organizations.

This report has been prepared by the Warld Health Organization Regional Office for the Western Pacific for governments of Member States in the Region and far those who participated in the Joint UNFPNWHO Meeting on 100% Condom Use Programme, which was held in Manila, Philippines from 3 to 5 October 2006.

CONTENTS

SUMMARY 1. 1.1 1.2 1.3

INTRODUCTION .................................................................. Objectives ........................................................................... " Participants and resource persons ................................................ . Organization ofthe meeting ....................................................... . Welcome statement. ................................................................ . Opening of the meeting ............................................................ . PROCEEDINGS .................................................................... . Viewing and discussion of posters................................................ Issues related to sex work .......................................... , ......... ....... Approaches to promote HIV prevention in sex work..... ..... ... . .. ..... ....... Lessons learnt from external reviews........ ...... ............................... Identifying strategies for scaling-up interventions.............................. Group sessions................................. ............. ............................... MSM and transgenders .............................................. ...... ......... Some interesting points regarding the 100% CUP....................... ....... Group work on country challenges and plans ............. .... ............... . Concluding activities and closing ceremony.................................. ... CONCLUSIONS AND RECOMMENDATIONS........... ... ................ Conclusions ................................. ,. .................. ................. ..... Participants recommendations to countries...................................... Participants recommendations to WHO and UNFP A..... ..... .... .. . ...... ... 1

1.4 1.5 2.

1 I I 2

2

2.1 2.2 2.3 2.4 2.5

2.6 2.7 2.8 2.9 2.10 3. 3.1 3.2 3.3

2 5 6 7 9 11 12 12 12 15 16 16 18 19

ANNEXES

ANNEX 1 ANNEX 2

AGENDA............................................................. LIST OF PARTICIPANTS, CONSULTANTS, TEMPORARY ADVISERS, OBSERVERS AND SECRETARIAT..................................................... COUNTRY POSTERS......................... .........................

21

23 31

ANNEX 3

KeyWords Sexually transmitted diseases - prevention and control/Acquired immunodeficiency syndrome - prevention and control / HN infections - prevention and control/Tuberculosis prevention and control/Condoms-utilization / Asia, Southeastern / Western Pacific

ABBREVlA TIONS

100% CUP 100%TCP AIDS APNSW CBO GFATM IEC HIV

100% Condom Use Programme 100% Targeted Condom Promotion (Myanmar) acquired immunodeficiency syndrome Asia Pacific Network of Sex Workers community-based organization Global Fund to Fight AIDS, Tuberculosis and Malaria information, education and communication human immunodeficiency virus most-at-risk group myths, misperceptions and fears (about condoms) men who have sex with men nongovernmental organization Population Services International sexually transmitted infection(s) trans gender Joint United Nations Programme for HIV/ AIDS United Nations Population Fund World Health Organization Women's Network for Unity (Cambodia)

MARG MMF MSM NGO PSI STI TG UNAIDS UNFPA WHO

WNU

SUMMARY

The WHO Regional Offices for South-East Asia and the Western Pacific, together with the United Nations Population Fund (UNFPA), organized a three-day Joint UNFPA/WHO Meeting on 100% Condom Use Programme (CUP). Objectives included the following: (I) to share and discuss the experiences and lessons learnt from the 100% CUP including assessments and evaluations conducted in the different countries; (2) to identify strategies to work with non-establishment-based sex workers;

to brainstorm and develop a roadmap on strategies for nationwide expansion of (3) the 100% CUP to be in line with universal access by 2010; and, (4) to identify support needed from WHO and other stakeholders in the process and to identify strategies to mobilize resources within the country and from donors. While recognizing that the 100% CUP has been one of the most effective public health interventions for the prevention and control of sexually transmitted infections (STI) and HIY related to sex workers, participants were also aware that some areas of the programme needed improvement. Among the shortcomings discussed in the meeting were: low levels of condom use among sex workers and their clients; apparent shifts in some areas to a preponderance of freelance sex work; the incomplete application and adaptation of the 100% CUP strategy to meet the public health needs of men who have sex with men (MSM), trans genders and sex workers who live in border areas; and the exclusion of sex workers in the planning and implementation of the programme. Conclusions and recommendations from the meeting urged countries and sponsoring agencies to step up efforts to address these problematic areas by assuring strong political support for the programme, organizing truly multi sectoral participation in all aspects of the programme, paying attention to the legal and human rights aspects of sex workers and their clients, and assuring that the 100% CUP is fully integrated in the national response to HIY /AIDS and STI.

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I. INTRODUCTION

!he W~O Regional Offices for South-East Asia and the Western Pacific, together with the Umted NatIOns Population Fund (UNFPA), organized a three-day Joint UNFPAlWHO Meeting on 100% Condom Use Programme (CUP). 1.1 Objectives: To share and discuss the experiences and lessons learnt from the 100% CUP including assessments and evaluations conducted in the different countries. (I)

(2)

To identify strategies to work with non-establishment-based sex workers.

(3) To brainstorm and develop a roadmap on strategies for nationwide expansion of the 100% CUP to be in line with universal access by 2010. (4) To identify support needed from WHO and other stakeholders in the process and to identifY strategies to mobilize resources within the country and from donors. The detailed agenda of the meeting is attached as Annex 1. 1.2 Participants and resource persons

The meeting was attended by 43 national participants from 16 countries including Bhutan, Cambodia, China, Fiji, Guam, Indonesia, Kiribati, the Lao People's Democratic Republic, Malaysia, Mongolia, Myanmar, the Philippines, Papua New Guinea, Sri Lanka, Thailand and Viet Nam. An additional 30 persons participated as secretariat members, consultants, temporary advisers or observers. Temporary advisers and observers included representatives from the Women's Network for Unity (Cambodia), Asia Pacific Network of Sex Workers (Malaysia), Family Health International (India), DKT Philippines, Joint United Nations Programme for HIV/AIDS (Philippines), UNFPA (Philippines); and United States Agency for International Development (Viet Nam). A list of all participants is found in Annex 2. 1.3 Organization of the meeting

The meeting was held at the Manila Pavilion Hotel in Manila, Philippines from 3 to 5 October 2006. Methods used in the meeting included presentations, small group discussions and plenary discussions. The WHO Regional Office for the Western Pacific provided technical and operational support for the meeting. 1.4 Welcome statements Representatives of the two sponsoring agencies welcomed the participants. Dr Richard Nesbit, Acting WHO Regional Director for the Western Pacific, thanked participants for travelling to Manila to participate in the meeting. He observed that the 100% CUP has stood out as one of the few success stories in the prevention of HIV/AIDS,

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beginning first in Thailand and Cambodia and being applied now in a half dozen other countries. Dr Nesbit also noted that the 100% CUP has helped advance human rights for sex workers. He made reference to other important approaches that are also contributing the prevention of STI and HN among sex workers, especially the Avahan and Sonagachi projects in India. Despite these successes, Dr Nesbit reminded the participants that basic prevention interventions for sex workers remains low, less than 20% in the region and worldwide. He applauded the efforts that participants were taking in their various national programmes and assured them that he looked forward to learning more about the results of the meeting. Dr Chaiyos Kunanusont, HNIAIDS/STI Adviser, UNFPA, expressed delight with the number of participants attending the meeting and shared Dr Nesbit's pleasure that the two agencies were jointly sponsoring the meeting. He stressed that all participants, whether supported by UNFPA or WHO, should view themselves as "clearly on the same team". He encouraged participants to think "outside the box" during the meeting. While noting that the 100% CUP had been a very effective programme for sex workers, he observed that sex work is now evolving and moving into challenging new areas like the use of the Internet and cell phones to negotiate sex. He explained that UNFP A was adding significant numbers of staff at the country level to support national programmes and was developing strategies for its work in the future. He pledged UNFPA's support to countries in the important area of HN and sex work. 1.5 Opening of the meeting

The meeting was formally opened by Dr Nesbit, who nominated Chairpersons for each day of the meeting: Dr Ernesto Eusebio S Villalon III (Philippines) on day one; Dr Gampo Dorji (Bhutan) on day two; and Dr Rohani bt Ali (Malaysia) on day three. The nominations were accepted by unanimous consent. Ms Gaik Gui Ong, HIV/AIDS/STI Technical Officer, WHO Regional Office for the Western Pacific, provided participants with an explanation of the formal objectives and organization of the meeting. She stressed the importance of trying to elaborate on intervention strategies for non-establishment-based sex work and on developing strategies for nationwide expansion of the 100% CUP. The provisional agenda was presented and accepted.

2. PROCEEDINGS

2.1

Viewing and discussion of posters (Agenda 3)

Dr Ernesto Eusebio S Villalon III, Chairperson, invited participants to look over the posters that had been prepared by the participating countries. The posters were designed to explain the current status of their prevention interventions for sex workers and their clients, especially as they relate to promoting the use of condoms. The posters were displayed on stands along the front wall of the meeting room; copies were inserted in the participants' meeting folders (see Annex 3). The contents ofthe posters are summarized as follows. Cambodia: The presentation from Cambodia reported on surveillance data that had been collected since 1998. The data demonstrated that the 100% CUP has more than doubled the use of condoms by brothel-based sex workers and, concurrently, halved the prevalence ofHIV. The use of condoms by several client groups of sex workers has also increased significantly. Cambodia has planned steps to take to strengthen the programme.

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Fiji: T?e presentation from Fiji highlighted a low level of condom use among sex workers despite the effort of nongovernmental organizations (NGOs) to advocate the use of condoms and to distribute them to sex workers and the establishments in which they operate. The poster concluded that multilateral consultation is needed to help strengthen and ensure condom use. Guam: The poster from Guam--popular Asian tourist designation and military basereviewed the activities of the Government and health facilities to prevent STI and HIY transmission, especially in entertainment establishments and massage parlours. The Health Department is now partnering with selected community-based organizations (CBOs) to encourage implementation and compliance with a 100% CUP. No data is yet available on condom use by sex workers and/or clients. Indonesia: The presentation from Indonesia discussed a growing concern with the concentrated HIV/AIDS epidemic in the country, including that related to sex work. The poster also outlined the critical programme components of the 100% CUP. Although condom use remains low in the country and authorities believe that implementing a 100% CUP will be difficult in Indonesia, it is one of the options that they are actively considering in their national HIV/AIDS strategy. Lao People's Democratic Republic: The poster presentation revealed that although the Lao People's Democratic Republic is still classified as a low HIV prevalence country, seroprevalence of HIV among sex workers has been increasing. The focus of the 100% CUP in the Lao People's Democratic Republic has been directed at creating an enabling environment; condom social marketing; targeted information, education and communication (lEC); and assuring condom availability. There are plans to scale up the 100% CUP nationwide by 2010. Mongolia: The poster from Mongolia showed data that suggested a disturbing increase in sex work, apparently related to the country's political evolution to an open market economy, modernization and urbanization. As most sex workers in Mongolia are freelancers, national authorities launched a relatively unique 100% CUP that works with sex-worker NGOs, the police and hotel owners so as to ensure condom use. The poster presented encouraging results from the initial pilot areas for the 100% CUP, along with a review of plans to expand the programme nationally with financial support from the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). Papua New Guinea: The presentation from Papua New Guinea stressed the problematic nature of sex work in the country and the strategies that have been employed to decrease STI and HIV rates among sex workers: condom social marketing, peer education and a 100% CUP policy. Despite these efforts, a number of studies have revealed that condom use remains low. The presentation discussed future activities that the Government is planning. China: After reviewing the extensive government activities focusing on high-risk groups in China, the presentation discussed the national experience with the 100% CUP, beginning first in four provinces and now expanded to 20. The poster also presented surveillance data that showed that condom use among sex workers increased significantly between 2001 and 2005. Philippines: The poster from the Philippines discussed the country's evolving efforts to control STI and HIV, culminating in 2002 with the initiation of a 100% CUP at four pilot sites. As a result of this programme, condom distribution in the country has increased markedly. There is indication that STI among registered entertainment workers have been reduced at social hygiene clinics. The Philippines is planning to expand the 100% CUP to an additional 21 cities in 2006.

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Sri Lanka: Sri Lanka presented a general review of the Government's condom promotion activities including: condom social marketing, free distribution, advocacy, improving knowledge, reducing stigma and improving care. The populations targeted for this preventive programme are broadly focused: sex workers, beach boys, transport and hotel workers, and security forces. Sri Lanka's health authorities believe that a scale-up of activities will be possible and will ultimately achieve 100% condom use. Viet Nam: Inspired by successful regional experiences with the 100% CUP, the Ministry of Health has implemented a decentralized programme in selected sites and has also supported NGOs with condom social marketing. The poster revealed that despite these programmes, condom use among high-risk populations is still very low. New strategies are being implemented to greatly expand HIV/AIDS services. OPEN FORUM

A general discussion of issues followed the viewing of the posters. A number of questions were raised about how country programmes respond when they identify an HIVpositive sex worker. Representatives from China and Thailand explained the activities they undertake to provide necessary treatment and prevention services to HIV -infected sex workers. Questions were raised about the accuracy of the number of sex workers that countries had estimated and it was wondered if countries were not overlooking many male and transgender sex workers. A participant from Thailand said that fairly careful studies in that country had not revealed many male and/or transgender sex workers working there. On the other hand, it was felt by other participants, including Fiji, that transgender sex workers were indeed an important factor in sex work. A participant from Bhutan said that sex work was seemingly so informally arranged in his country that he had difficulty even in defining what a "sex worker" was in the national context. A participant from the Philippines agreed that It was often difficult to define "sex workers", especially when including sexual minorities like men who have sex with men (MSM) and transgenders. A participant from China said that they were developing a fairly extensive programme to address male sex work. Ms Gaik Gui Ong reminded participants that an international consultation dealing specifically with male sexual health and HIV in Asia and the Pacific had recently been held in New Delhi, India. The draft conclusions and recommendations from that meeting were shared with the participants. An extensive discussion surrounded questions about how much of an obstacle was presented to 100% CUP because of the illegality of sex work. A number of other participants explained that despite the formal illegality of sex work in their countries, they were in fact working cooperatively with security services (military, police and border patrols). However, such cooperation between health authorities and public security was predicated upon both a good understanding of the risks of HIV /AIDS to the community and a high level of political support. Despite the difficulties that are sometimes encountered in working with public security offices (e.g. reluctance of sex workers to work openly with police officers), it was generally agreed by participants that it was necessary to have their active participation in condom use programmes.

Another series of exchanges took place among participants about the complexity of dealing effectively with sex workers in border regions (i.e. cross-border sex) and also with the trafficking in women and children. A participant from China said that it shared borders with Myanmar, Viet Nam and Thailand and was trying to increase collaboration with these countries regarding sex work in border areas.

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A discussion of condom availability and supply led to agreement that the 100% CUP was concerned with much more than just the supply and availability of condoms. Its focus was on the use of condoms. Another participant stressed that condom promotion must be fully integrated into the national response to HN/AIDS. At the same time, it was recognized that condom supply, especially the uninterrupted supply of condoms, was a critical programme component that should not be undervalued. A number of countries also expressed an interest obtaining more supplies of female condoms and integrating their promotion into the national programmes. 2.2 2.2.1 Issues related to sex work (Agenda 5) Condom myths, misperceptions and fears

Dr Chaiyos Kunanusont, HNIAIDS/STI Adviser, UNFPA, made a presentation on the many myths, misperceptions and fears (MMFs) about condoms that adversely affect their acceptance and use by sex workers and the public. He discussed a few of the more than 200 condom MMFs that UNFPA had assembled and organized as product related, consumer related and provider related. He outlined the ways to address MMFs including: improving knowledge, creating a positive attitude and developing skills to promote condom use among targeted groups. Dr Chaiyos informed participants that UNFPA had developed a detailed manual about MMFs and approaches to resolve them, as well as a set of six concise "fact sheets" on condom use, including the use of female condoms. 2.2.2 100% CUP: poverty, gender and human rights issues

Mrs Anjana Bhushan, Technical Officer, Poverty and Gender, WHO Regional Office for the Western Pacific, outlined the ways that poverty contributes to sex work and thus high risk of HN and STI. In addition, she pointed out that gender inequalities in education, power and susceptibility to violence also increase the vulnerability of women to STI and HN. Sex workers are also confronted with a number of human rights abuses related to their stigmatization, marginalization, sexual exploitation and lack of protection from violence. Mrs Bhushan expressed the opinion that the 100% CUP has seemingly been organized in countries in ways that expand respect for the human rights of sex workers. At the same time, she expressed concern about the way the programme has been implemented and designed as it relates to confidentiality, registration of sex workers, corruption and use of "mystery clients". 2.2.3 Current status of sex work in Asia

Ms Khartini Slamah, Coordinator of the Asia Pacific Network of Sex Workers (APNSW), presented a broad range of problems facing sex workers. Stigma and discrimination were believed to be the "main drivers" of sex workers' vulnerability. The presentation also focused on affordable health service needs of male and transgender sex workers. The cost of drugs for STI and HN care were of special concern in the presentation. Gender-based violence against sex workers is also a common abuse confronted along with what Ms Siamah believed were serious violations against human rights, including those associated with the 100% CUP. Finally, Ms Slamah presented the history and goals of the APNSW, which was formed in 1994 as an international organization of a number of national organizations of sex workers. OPEN FORUM

The ensuing discussion focused on concerns by some about the human rights issues surrounding the 100% CUP. In response to a question from one participant, Ms Siamah elaborated that her organization was not categorically against the 100% CUP, although they

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had serious concerns about how it was being implemented in some areas. Mrs Bhushan agreed that many of the problems stemmed from how it was being implemented, although she still felt there were questionable areas related to policy and design. Dr Wiwat Rojanapithayakorn, HNIAIDS Team Leader, WHO Beijing, said that he felt most of the problems encountered were those related to implementation and misunderstandings about what the programme entailed. For example, the "no condom, no sex" policy was designed to protect sex workers. Also, mandatory health exams for sex workers were not in fact an integral part of the 100% CUP strategy. A participant from Cambodia explained that there has been much progress with the 100% CUP through the years. An association of sex workers is involved in the programme and helps to promote protection for sex workers. All the problems of abuse, also, have not necessarily been those of "human rights abuses". Dr Wiwat said that, despite many claims to the contrary, he had seen no real evidence that the 100% CUP is "the cause" of women migrating to more dangerous street work. Many other factors appeared to be fuelling increases in street-based sex. Ms Gaik Gui Ong said that an early study of the 100% CUP in Cambodia had indeed pointed to a number of human rights issues, particularly related to police abuse. She explained further though that a foHow-up external review concluded that it appeared some abuses existed long before the 100% CUP and that, in fact, it appeared that abuses had been greatly reduced as a result of the programme. 2.3 Approaches to promote HIV prevention in sex work (Agenda 6)

2.3.1 Approaches to promote HIV prevention in sex work: developing responses in local contexts Dr Farah Usmani, HIV/AIDSIRH Adviser, UNFPA, reported on a number of recent developments in UNFP A. A draft "global framework" for a rights-based approach to HNIAIDS and sex work has been developed, fol1owing a consultation in Brazil in July 2006. This framework is based on three pillars: reducing vulnerabilities, supporting and scaling up services and promoting participation. In recognition of the diverse nature of sex work and different responses to it, the UNFPA has also developed a framework that can be used to catalogue responses in six different approaches: (1) targeted interventions for sex workers/clients; (2) registration and regulatory; (3) community-led mobilization; (4) social developmentlempowennent; (5) solidarity building and government policy; and (6) health services. Finally, Dr Usmani stressed the need for health agencies to be flexible in tailoring activities so that they can be responsive to the local contexts, capacities, priorities and needs. 2.3.2 Support to Avahan interventions with sex workers in India

Dr Teodora Wi, Director, STI Capacity Building, Family Health International, India, presented infonnation on Avahan, a bold new initiative financed by the BiIl & Melinda Gates Foundation. Avahan's prevention programmes are focussed in six Indian states and along national highways. These areas have been hit particularly hard by India's still growing lIN/AIDS epidemic. There is also evidence of a generalized epidemic with infection rates less than 1.5%. The programme is targeting core and bridge groups with both risk and vulnerability reduction programmes, including condom promotion. Essential STI screening and treatment services are being provided to participants on a voluntary basis as an integral part of strong efforts at advocacy, capacity-building, mobilizing partners, community participation and monitoring and evaluation. Increases in condom use have been seen in evaluations among both

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brothel- and non-brothel-based sex workers. The number of persons receiving STI services through outreach has risen rapidly over the past year and a half of ope~ation and ther~ has been a reduction in observed ulcerative STI. Programme managers are lookmg forward to mcreasmg STI service utilization and condom use even more in the coming period. It is planned also to create a sustainable environment in the community to continue support for the programme and to other HIVI AIDS needs of sex workers. 2.3.3 Approaches to promote HIV prevention in sex work: creating an enabling environment for the 100% Condom Use Programme

Dr Wiwat Rojanapithayakorn began his presentation with a review of the essential principles of the 100% CUP, stressing that it was about increasing condom "use" and not just about condom promotion and availability. He helped participants to distinguish between an enabling environment, a conducive environment, and an "unabling" environment. Among the important factors in creating an enabling environment were: government policy support; inclusion into national HIV/AIDS strategies; and a multi sectoral institutional arrangement with the participation of the health sector, police sector, local administration sector, sex business sector, other government sectors, NGOs, the media and donors. Creating a system for effective and efficient monitoring of the programme was presented as a vital activity supporting a conducive environment for the 100% CUP. In this regard, Dr Wiwat stressed the need to have provisions to monitor condom "use". 2.3.4 Sex workers in Cambodia

Ms Keo Tha, Director, Women Network for Unity (WNU), provided participants with an overview of her organization. Located in Phnom Penh, Cambodia, WNU was founded in 2002 with the support of eight NGOs. It became independent at the end of 2002, and was subsequently registered with the Ministry of Interior in mid-June 2004 as a local association. Ms Keo Tha outlined a number of problems faced by sex workers in Cambodia, including stigma and discrimination, violence, poverty, lack of access to health services and the unavailability of condoms. Despite the problems, she pointed to a number of achievements of her organization of 5000 members, now affiliated with the APNSW, in building solidarity and helping to advance human rights for sex workers. OPEN FORUM

A question was raised about how the 100% CUP could be applied to non-establishmentbased or freelance sex workers. A participant from Cambodia said that they had focused initially on establishment-based sex workers because it was the predominant form of sex work when they began. Now they are looking to expand the programme to include freelance sex workers. It was generally agreed that the experience in Mongolia was probably the best model to follow. In this discussion, the dilemma of how to deal with sex workers who communicate with clients via cell phones and SMS messaging was again raised though not resolved. It was suggested that this issue be addressed in the group work session scheduled for the next day. 2.4 Lessons learnt from external review (Agenda 7)

Preceding this agenda item, Dr Robert Fischer, consultant, provided a brief overview of the results of the first day's work.

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Dr. Ma. Elena Borromeo, UNAIDS Country Coordinator, Philippines, also made a brief presentatIOn on ho,,:, programme managers had worked closely and carefully with the Catholic Church. III the PhllIppmes so as to gain their understanding of condom promotion for HIV prevention: Although the Church ha~ strict teachings concerning sexual morality and contraceptIOn, UNAIDS and the CatholIc Church leadership were able to resolve differences wIthout confrontation. 2.4.1 The 100% Condom Use Programme in Thailand Dr Pachara Sirivongrangson, Director of STI Cluster, Department of Disease Control, Thailand, presented that pre-existing provincial STI prevention and control infrastructure contributed to both the rapid implementation and positive results seen in the 100% CUP implementation. These results included both an increase in condom use among establishmentbased sex workers and a reduction in the incidence of STI. Also, data from male STI clinic patients has shown a decrease in infections that could be attributed to contact with sex workers. Despite these successes, Dr Pachara outlined a number of new obstacles that the programme is now facing due to general health infrastructure reforms and budget cuts. An external review of the health sector's response to HIV/AIDS in Thailand also pointed to problems in the programme related to insufficient outreach efforts to sex workers and to signs of increased risk of HIV infection among MSM, trans genders and other minorities like prisoners and drug users. There is fear that the epidemic, for a while seemingly in retreat, threatens to regain momentum in communities where complacency has set in. 2.4.2 100% Targeted Condom Promotion in Myanmar Dr Nyan Tun, State AIDS/STD Officer, State Health Department, Myanmar, announced that the number of townships participating in the national 100% Targeted Condom Promotion programme (100% TCP) has been increasing since its inception in March 2001. The programme has been expanded from four pilot townships in 2001, to 154 townships by 2006, with the support of six United Nations agencies and GF ATM. His presentation included criteria for the selection of participating townships, five essential components of the 100% TCP and model township budgets. Dr Tun stressed that the high cost of transporting condoms in his country was a major challenge for the 100% TCP. Other challenges for the programme have included difficulty in gaining political and police cooperation at the local level as well as difficulties related to the varied nature of sex work settings in Myanmar. 2.4.3 Lessons learnt from the 100% CUP external review in Cambodia

Dr Lan Van Seng, Deputy Director, National Center for HIV/AIDS, Dermatology and STDs (NCHADS), Cambodia, presented an overview on an external review of the Cambodian 100% CUP in 2003. After a study of documents, discussions with stakeholders and a number of field visits the international reviewers came to a number of conclusions, including: (I) coordin~tion among NGOs and between NGOs and the government has been weak; (2) both police and health workers have been registering sex workers; (3) there has been much mobility among sex workers that had not been well accommodated, especially the back-and-forth movement between freelance and brothel-based sex work. As a result of this study, Cambodia has developed a Condom Working Group with clear terms of reference, has increased the participation of sex workers in the programme, and has established a human nghts mOl1~t?nng group in their Condom Use Coordinating Committee. The view among national authontJes IS that most of the recommendations of the external evaluation are now being addressed adequately.

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OPEN FORUM

One participant noted that Thailand is seemingly a "victim of its own success". Because it achieved such a reduction in STI and Hrv, Thailand is now having difficulty mobilizing political support and funding. Myanmar, too, was recognized as a country now confronting funding problems. A participant from the Pacific islands noted that they share the costly problem of shipping condoms to remote areas. On the other hand, a participant from Malaysia observed that it was impressive how many condoms had in fact been distributed in these areas despite the financial challenges. A question was raised about the desirability of having free distribution of condoms and whether Myanmar had plans to integrate condoms supplied by Population Services International (PSI) into their own governmental budgets at some point in the future. A UNFPA representative expressed the opinion that distributing condoms free of charge was sometimes necessary and therefore understandable. Myanmar said that PSI condoms were not being freely distributed and thus the Government was not looking forward to any necessity to absorb these costs. Dr Wiwat advised that, in the circumstances where countries need to back away from distributing free condoms because of economic constraints, they should do so gradually so as to avoid precipitous ruptures of availability to those in need. He also observed that there are substantial savings that accrue to government services when there is a reduction in STI. Thus, it is reasonable that governments invest money in providing free condoms to those in need. In the final analysis, Dr Wiwat encouraged participants to think more about expanding the 100% CUP activities rather than looking at options for retreating. 2.5 2.5.1 Identifying strategies for scaling up interventions (Agenda 8) 100% Condom Use Programme in Hubei, China

Ms Li Jia, Assistant Researcher, National Centre for AIDS/STD Control and Prevention, Chinese Centres for Disease Control and Prevention, Beijing, provided an overview of the 100% CUP in Hubei China. Begun first as a pilot study in Wuhan City in 2000, it has heen extended to the whole of Huhei since 2004. Evaluation data presented demonstrated an increase in consistent condom use by female sex workers to 80% by late 2005. STI rates have declined with equal success. The lessons learnt from this programme point to the importance of strong governmental leadership, multi sectoral participation, and good cooperation from establishment owners. Despite the success of this programme, organizers are of the view that it is difficult to have sustained behavioural changes for a risk group like sex workers in a short period of time. They believe that a 100% CUP should be seen as a long-term strategy for HIV prevention. 2.5.2 Strategies for expansion of the 100% CUP in Cambodia

Mrs Chou Bun Eng, Director-General, Ministry of Women's Affairs, and Former Executive Director, Cambodian Women for Peace and Development, reviewed some of the accomplishments of the 100% CUP in Cambodia as the basis for understanding the Government's commitment to scaling up the programme. Future plans are to maintain political support, outreach, condom availability, STI services and the active involvement of local authorities. The programme in Cambodia has also recognized that although sex work is illegal, there has been great advantage to have sex workers who are "open", "reachable" and "empowered" advocates and participates in the programme. Building on past progress in

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expanding sex workers' capacity, expansion plans foresee a need to organize even greater involvement for sex workers in the future. 2.5.3 Use of Global Fund for nationwide expansion of the 100% CUP in Mongolia

Dr Chultem Baigalmaa, Medical Officer, AIDS/STI Department, National Center for Communicable Diseases, Mongolia, explained that the 100% CUP in Mongolia has been implemented in two phases: (1) a pilot phase between 2002 and 2005, and (2) a nationwide expansion between 2005 and 2008. A critical part of the expansion of the 100% CUP in Mongolia has been the financial support received in Round Two and Round Five of the GF ATM. Though the need to work with hard-to-reach freelance sex workers still challenges the programme, good collaboration with the police authorities and a system of a coded "green card" for sex workers has done much to facilitate their cooperation with the programme. Especially challenging to the expansion of the programme is the high turnover of staff in government service and a poor system for monitoring and evaluating programme outcomes. Mr Delegchoimbol Amarsaikhan, Head of the Orkhon Aimag Police Department, Mongolia, gave a brief presentation on the participation of police authorities in the 100% CUP in Mongolia. He noted that sex work has been increasing in Mongolia and that it was a criminal offence until 2002. However, police efforts to eradicate sex work had not been successful. With recognition that HN is a very dangerous disease for Mongolia, there has been agreement to decriminalize treatment of sex workers and the need to cooperate with the 100% CUP. He said that the police authorities in Mongolia fully understood and agreed with this strategy. 2.5.4 access Monitoring and evaluation of scaling up sex work interventions towards universal

Dr Nguyen Thi Thanh Thuy, HNIAIDS/STI Epidemiologist, WHO Regional Office for the Western Pacific, presented a monitoring and evaluation framework with examples of types of data that could be used to track progress in a 100% CUP. Beginning with a situation analysis for planning effective interventions, she gave examples of the types of indicators that could be used to monitor and evaluate inputs, processes, coverage, outputs, outcomes and impacts of a 100% CUP. Dr Thuy explained that it was important for programme planners to select only a few realistic indicators to use in the programme. She also stressed that having information on impact of the programme (Le. changes in health outcomes that are plausibly linked to overall programme effort) were very important in gaining political support for scaling-up. Among the key principles for a monitoring and evaluation system, Dr Thuy stressed that indicators had to be realistic and measurable and that there should be a clear definition of population sources, numerators and denominators. She referred participants to a list of useful documents elaborating on the issues covered in her presentation.

OPEN FOR UM Some participants expressed concerns that the participation of police could discourage sex workers from collaborating. A participant from China admitted that although it was sometimes controversial to have police working in a health programme, their participation was a vital component to the 100% CUP. Another participant expressed appreciation for the presentation of the police official from Mongolia, noting also that it was the role of the police not only to enforce rules, but also to protect the human rights of sex workers. Another participant expressed disappointment that every discussion of programme expansion had not included mention of an expansion of the participation of sex workers, which was clearly a vital component of the programme.

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2.6

Group sessions

Participants broke up into four self-selected groups that were to address various strategic challe~ges of the 100% CUP. Facilitators for the groups were provided by the sponsoring agencles and each group selected a rapporteur. After working together for the first half of the afternoon session, presentations were made on group fmdings and deliberations. 2.6.1 Group 1: Strategies for nationwide expansion including support needed from UNFP NWHO and other stakeholders

Group 1 noted that before scaling up the 100% CUP, it was important to have a sound programme design for "no condom, no sex" including an enabling environment, a national multisectoral leadership group, good participation of most-at-risk groups (MARG) and good integration of the 100% CUP into the national response to HIV/AIDS. A multistep process for scale-up was identified including the development of technical and operational guidelines for expansion, identification of new geographical sites and new target groups, consensus-building among stakeholders, capacity-building, and development of an implementation plan. The group also stressed the critical need for the expansion to include the development and implementation of an expanded monitoring and evaluation system. Finally, the group identified a number of areas where support from WHOIUNFPA and other stakeholders could be anticipated including technical support for a country-level review of the CUP and identification of new strategies, advocacy support, and assistance with commodity security. 2.6.2 Group 2: Mechanisms for monitoring and evaluation

This group determined that it was important to have the establishment of responsible health agencies for monitoring and evaluation at all levels of operation of the 100% CUP: national, provincial and district. Before determining the indicators to be tracked, it was important to be clear about the identity of the target population (e.g. type, size, and location) and the components of the intervention package. The group selected a number of indicators that they thought were important in the area of programme input, process, outcome and impact. Finally, the group looked at issues concerning the frequency at which data would be collected and the sources from which it could be obtained. They stressed however that these indicators and sources had to be tailored to each programme individually. 2.6.3 Group 3: Strategies for mobilization of resources

This group developed a model four-step plan for mobilizing resources. The first step was to establish a national multisectoral task force to develop proposals for the 100% CUP. Proposals should be designed to insure that all plans and activities are consistent with the National Strategic Plan on HIV I AIDS and ST!, especially in the areas of human resources, capacity-building, infrastructure and related services like voluntary counselling and testing (VCT), IEC and the prevention of mother-to-child transmission of HIV. Proposals should also have an analysis of existing available resources and incorporate knowledge of evidence-based best practices from within the country and from other countries. 2.6.4 Group 4: Strategies to work with various forms of sex work

Because of the large number of participants who selected to work with this group, it was arbitrarily divided into two sections so as to facilitate a good exchange of views. Both sections worked first on identifying examples of brothels and brothel-like venues that existed for sex work in addition to a large number of non-establishment types of sex work. One section decided to classify sex work as either establishment-based or non-establishment-based on the

- 12 -

basis of whether sex workers worked for or were supervised by someone else or whether they worked alone. With this scheme, strategies for intervention could be tailored toward working primarily with the supervisors or other gatekeepers (as in the 100% CUP) or with sex workers themselves (as in the Sonagachi programme). Depending upon the type of sex work involved, all strategies for prevention interventions involved the creation of an enabling environment, involving the sex workers in all stages of programme planning and implementation, community capacity-building, strict attention to confidentiality and the involvement of establishment owners and managers where they exist. 2.7 Men who have sex with men and transgenders

Because of the recurrence of issues around sex work involving MSM and transgenders, an additional agenda item was organized and inserted into the programme. Ms Khartini Slamah reported briefly on the results of the international consultation "Male Sexual Health and HIV in Asia and the Pacific", which had been conducted in New Delhi, India, from 23 to 26 September 2006. Ms Slamah referred participants to a handout from the meeting titled "Principles of Good Practice: Towards Universal Access to HIV Prevention, Treatment, Care and Support for MSM and Transgenders". She stressed that MSM and transgenders were quite different in terms of sexual orientation and identity, sexual practices and health care needs, and that neither group was necessarily involved in or exempt from sex work. Both groups are in need of comprehensive health services and the 100% CUP "can't do it all". She also expressed satisfaction that physicians and religious leaders had joined together in this New Delhi meeting for a good exchange of ideas and she thanked participants at this meeting too for including her participation. 2.8 Some interesting points regarding the 100% CUP

Dr Wiwat Rojanapithayakorn made a presentation to address a variety of issues that had been raised during the course of the meeting. Observing that some participants had used the term "non-classical" 100% CUP to refer to programmes for freelance sex workers, he reminded participants that the "classical" 100% CUP included three critical components: (I) government authorities and sex business sector work together to empower all sex workers to refuse sex without a condom; (2) customers are no longer in control of sex services with regard to use of condoms; and, (3) local authorities and the sex business sector are responsible for promoting and maintaining this enabling environment. He said that the 100% CUP was in fact very easy to implement and that it has been proven to be effective. The real difficulty with the 100% CUP is the issue of convincing policy-makers to support this approach. After running through a series of slides presenting data on the 100% CUP in Thailand, he addressed a number of issues on condom supply and quality including the pros and cons of free versus commercial versus social marketing of condom supplies. 2.9 Group work on country challenges and plans

On the basis of information and perspectives gained during the meeting, country participants were asked to make a brief presentation on the key constraints and challenges they face in scaling up sex work programmes in their countries as well as the key activities they plan upon their return home. Where applicable, the participants were also asked to identify technical and financial SllppOIi needed for these activities. Participants made brief reports on their challenges, plans and needs. Cambodia: The key constraints and challenges confronting the Cambodia programme include: a lack of collaboration between the government and NGOs and among NGOs; weak coverage for non-brothel-based sex workers; limited links between outreach/peer education and

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the 100% CUP; and inadequate IEC materials for the 100% CUP. Key activities for scaling up prevention interventions include: regular coordinating meetings between the stakeholders; conducting an assessment and mapping of non-brothel-based sex work; strengthening capacity; and the development oflEC materials. China: The key constraints and challenges identified by participants from China include: a lack of qualified staff; insufficient funds; weak strategies suited for addressing sex work among drug users; a gap between existing policies and implementation; moral standard conflicts; and low awareness about HIV/AIDS among local authorities. Planned activities include: advocating for nationwide expansion of the 100% CUP; developing an annual work plan; building capacity through training, organizing study tours and meetings for experience sharing; developing strategies for enhancing interventions, including an expanded 100% CUP for male sex workers and transgenders; and strengthening supervision, monitoring and evaluation. Support is needed to fill technical and financial gaps.

Eili: The principle challenges and constraints identified in Fiji stem from: the illegal status of sex work; religious influences in the community; and inadequate financial, technical and commodity support. Activities planned for the short term include: strengthening technical, financial and commodity support to NGOs working with sex workers; strengthening multisectoral committees that are coordinating sex worker programmes; insuring that the 100% CUP is integrated into the existing HIV/AIDS and STI national plans; and building capacity in sex work activities at the national level. In the long term, the Ministry of Health plans to increase efforts to elaborate and implement policies for sex work programmes. Guam: The chief challenges and constraints identified for Guam include: a shortage of staff in the unit responsible for condom promotion; difficulty in penetrating networks of MSM and migrant sex workers; and anticipation that plans for a substantial increase in US military basing in Guam will greatly add to STI and HIV prevention and care needs. Health authorities are plarming to identify stakeholders to identify strategies to address the public health impact of increased military basing in Guam. In addition they have planned the following activities: identifying key persons from among the migrant and sex worker groups to work with NGOs and health authorities as peer educators; developing ties with trans gender and MSM sex workers; and promoting drop-in centres in conjunction with a new CBO and a government facility. Kiribati: The key challenges and constraints identified in Kiribati include: inadequate coverage of the peer education programme; insufficient condom supplies at the Maritime Training Centre; inadequate supplies of female condoms on Tarawa; weak support for the 100% CUP by the National HIVI AIDS Taskforce; and lack of knowledge and skills of health service providers in sexual and reproductive health. Plans for the future include: strengthening the Peer Education Programme in sexual and reproductive health for in- and out-of-school youth; strengthening the 100% CUP in the Seafarers' HIV Awareness Programme; reintroducing female condoms for targeted vulnerable groups and the general population; establishing a Condom Use Focal Person in the National HIV/AIDS Taskforce; and building the capacity of public health nurses including for the 100% CUP in public health services and the link with VCCT. Lao People's Democratic Republic: The key constraints and challenges confronting the Lao People's Democratic Republic include: an increase seroprevalence for HIV and high STI infection rates among service women; high mobility of service women; low knowledge of HIV/AIDS and STI; and low condom use. Activities to be implemented include: a follow-up permission/decree from local governments; set-up of a 100% CUP Committee and teams with clear terms of reference; revision of the 100% CUP Implementation Plan; increased condom

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distribution through outreach, drop-in centres, social marketing; scale-up of the 100% CUP to 11 provinces in 2007 and nationwide by 2010. Technical and financial support is needed from WHO!UNFPA. Malaysia: The principle challenges identified for Malaysia include: social and cultural constraints about condom use; imprecise knowledge about the magnitude and location of sex work in the country; lack of knowledge about the current status of condom use; and the need to identify areas in which to strengthen the capacity of stakeholders. Activities that are planned for the future include: developing national guidelines on the principles of condom use to be used for advocacy work; undertaking studies to develop more firm estimates on the size and location of sex workers in the country and the patterns of condom use; strengthening STI syndromic treatment and vcr and counselling; and strengthening capacity of stakeholders and new partners. Malaysia is also committed to the principle that the 100% CUP remains a part of the national HNIAIDS strategic plan and does not evolve into a stand-alone programme. Mongolia: The participants said that Mongolia's main challenges were the need to address the needs of freelance sex workers, the lack of capacity of sex workers non-government organizations/community-based organizations, weak coordination between implementing partners and a high tum-over of staff in the government and private sector. Future activities will include: advocacy meetings with provincial authorities on the implementation of the 100% CUP in several provinces; working group meetings in nine districts of Ulaanbaatar on progress in the implementation of the 100% CUP; establishing several provincial drop-in centres; and, supporting NGOs and sex worker self-help groups in their outreach activities. They are looking forward to more technical and financial support from WHO and UNFP A in all these areas. Papua New Guinea: Principal challenges identified for Papua New Guinea include: the extreme geographic, linguistic and cultural diversity of the population; weak political commitment for the 100% CUP; weak coordination; and insufficient human resources. Plans for the future will include: strengthening the national 100% CUP Committee; reviewing legislation, policies, strategies and reports on the 100% CUP; conducting a workshop on the 100% CUP for stakeholders; revising STI treatment protocols; and installing condom vending machines in venues accessible to sex workers and clients. Philippines: The key constraints and challenges confronting the Philippines include: identifying hidden populations of sex workers; ensuring compliance of the business sector to the 100% CUP; adequate supplies of condoms and lubricants; support and cooperation of local police; capacity development; varying levels of acceptance for condom promotion by local government units; local policies that regulate the sex industry; and resource limitations. Three activities are planned for the immediate future: (I) an assessment of ongoing 100% CUP pilot initiatives; (2) identification of new sites for expansion; and (3) roll-out of enhanced STI comprehensive case management. The Philippines is looking to international partners for technical and financial support as well as for a sharing of strategic information, policy advocacy and resource mobilization. South and South-East Asian countries: Five countries from South and South-East Asia joined in a common presentation. Bhutan was most challenged by the need for mapping of sex work in the country and also issues related to cross-border sex work. Myanmar identified the political and cultural constraints in the country as well as the high mobility of sex workers as most problematic. Thailand was most concerned about capacity-building and cross-border sex. The participant from Indonesia said its programmes were most challenged by the lack of political and governmental commitment. Sri Lanka was most constrained by the links of STI and HNIAIDS policy. Challenges common to all countries were general shortfalls in funding and the need for capacity-building among NGOs, health teams and for social marketing.

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Planned activities for these countries include: advocacy for policy-makers; establishment of a national multisectoral task team; skill-building for health workers and NGOs; sex worker mapping; and, development of a minimum package guideline for sex worker interventions. The group identified needs from WHOfUNFP A for technical assistance in the development of guidelines and tools for training. Financial support was also identified in the areas of support for meetings and training and training materials. Finally it was felt that assistance was necessary with coordination and common programme between countries in the area of cross border sex work. Viet Nam: The key challenges and constraints identified for Viet Nam include: a new HIV/AIDS law that provides for the 100% CUP but there are yet no documents to guide implementation; imprecision in the estimates of the number of sex workers in the country and the number of condoms needed; misunderstandings among local authorities about the 100% CUP; law enforcement efforts among entertainment establishments have caused sex workers to move to street work where they are more difficult to reach; questions about the quality of condoms; and insufficient evidence about the quality of outreach and social marketing programmes. New activities planned are: development of guiding documents to implement the new HIV/AIDS law; conduct of a situation analysis to better estimate the number and location of sex workers and condom needs; advocacy and promotion of the 100% CUP for local authorities; strengthening of monitoring and evaluation for harm reduction and condom social marketing programmes; and improvement of coordination among various stakeholders such as unions, police and health authorities. 2.10 Concluding activities and closing ceremony Prior to the closing ceremony, there was an open forum discussion on issues that should be included in the conclusions and recommendations of the meeting (see section 3 below). Dr Bernard Fabre-Teste, Regional Adviser for STI including HIV/AIDS, WHO Regional Office for the Western Pacific, introduced participants to two distinguished guests who were joining for the closing ceremony: Dr Kevin DeCock, Director, and Dr Tegueste Guerma, Associate Director, of the HIV/AIDS Department at WHO Headquarters in Geneva. He welcomed the guests on behalf of participants. Dr Chaiyos Kunanusont, HIV/AIDS/STI Adviser, UNFPA Bangkok offered some closing remarks on behalf of UNFPA. He observed that participants had been very active and vocal during the meeting and he thanked everyone for their contributions. Dr Chaiyos also expressed his great satisfaction with the collaboration he had seen between WHO and UNFP A at the meeting. He noted that this meeting was indeed a "joint" effort between the two organizations and he stressed that this was a "flexible joint" partnership that was prepared to work closely with national governments and stakeholders in pursuing the important work of HIV and STI prevention. He again thanked all assembled for their participation. Dr Kevin DeCock expressed his pleasure to be able to make a few observations at the

closing ceremony. He said that there had been much interest in recent years on advances in AIDS treatment, but that it was now time to refocus on prevention. In this regard he noted that the 100% CUP was a remarkable success story in the area of prevention and that it must be preserved and expanded in the Asia and Pacific region. In contrast to the theoretical prevention strategies that were being discussed in global forums, the 100% CUP was real, realistic and proven. He concluded that it was an appropriate prevention intervention for the kind of concentrated HIV epidemic that is found in many countries in the region.

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Dr DeCock discussed briefly some of the new efforts that WHO would be undertaking in the context of the "five strategic directions" in the organization's Global Strategic Plan for Universal Access: (1) enabling people to safely know their HIV status through confidential my testing and counselling;

(2) (3) (4) (5)

maximizing the health sector's contribution to HIV prevention; accelerating the scale-up ofHIVIAIDS treatment and care; investing in strategic information to guide a more effective response; and strengthening and expanding health systems.

Observing that less than 10% of people worldwide know their HIV serostatus, Dr DeCock said that WHO would be undertaking initiatives to try to increase knowledge of serostatus so individuals could voluntarily undertake preventive measures. WHO would also be seeking to redress current shortcomings in prevention of HIV among children and injecting drug users. In conclusion, Dr DeCockjoined with Dr Chaiyos in thanking participants for their work in this meeting and he wished them a safe journey home.

Dr Bernard Fabre-Teste formally closed the meeting on behalf of the joint sponsors. 3. CONCLUSIONS AND RECOMMENDATIONS

3.1

Conclusions

3.1.1 Participants clearly understood and recognized that sex work has been an especially important factor in STl and HIV epidemics in many countries in Asia and the Pacific. Several countries have adopted public health programmes, each adapted to local, political, cultural and epidemiological circumstances, which have been directed at preventing the acquisition and spread of STI and HIV among sex workers and their clients. 3.1.2 Participants understood that the 100% CUP has been highly effective for the prevention and control of STl and HIV related to sex work. When implemented on a large scale in countries where sexual transmission ofHIV is predominant, remarkable reductions in STl and HIV rates have been documented not only among sex workers and their clients, but also among the general population as well. There is good evidence of the programme's effectiveness in both direct and indirect sex work settings, and adaptations are being successfully scaled up where sex work is predominately street-based. 3.1.3 Participants gained a greater understanding of the key principles of the 100% COP:

(1) Authorities and sex businesses will work together to create an enabling environment to empower sex workers to refuse sex services if customers do not want to use a condom.

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(2) Customers will be no longer in control of the sex services with regard to the use of condoms. (3) Local authorities and owners of sex businesses are responsible for promoting and maintaining an enabling environment. 3.1.4 Participants agreed that the elements of any successful condom use programme include: (1) strong political commitment at the relevant levels of government in order to advance policies and activities to: (a) establish condom use as the nonn in all sex work (i.e. "No condom, No sex"); (b) engender the cooperation of sex business owners, managers, public security and other gatekeepers; (c) (d) ensure adequate supply of quality condoms; undertake activities to reach female, male and transgender sex workers;

(e) assure the availability of STl services for sex workers and their clients and partners; (f) provide for sound programme management and monitoring and evaluation systems. (2) (3) multisectoral responses; and active and effective involvement of all sex workers.

3.1.5 Participants also recognized that the international community faces persistent and/or newly evolving challenges that have not yet been fully confronted and resolved in preventing STI and HIV transmission related to sex work. (1) There is still low condom use and insufficient coverage of HlV prevention programming for sex workers in Asia and the Pacific. (2) A number of countries have reported increases and changes in types of sex work that require changes in strategies for interventions. Several countries noted a shift from establishment-based sex work to less-centralized street-based types of work or those whose contacts are organized through modem communication such as cell phones or Internet links. (3) The 100% CUP and other targeted preventive strategies have not yet been fully adapted and implemented as they may apply to addressing the individual and public health needs of sex work involving males and transgenders, sex work in international border areas, and the important nexus of sex work and drug use. (4) Sex work takes place in settings where basic human rights are frequently compromised or violated. Heightened vigilance is needed to assure that targeted prevention interventions do not aggravate or unwittingly acquiesce to such abuses.

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(5) There are many unmet opportunities for more fully and effectively involving the participation of sex workers in all aspects of programme design, planning and implementation. This concern persists despite some noteworthy progress that has been seen in the 100% CUP and other targeted prevention programmes in helping to empower and reduce the social marginalization of sex workers. (6) There is inadequate understanding about the strategies and cost benefit of the 100% CUP and thus a waning of national political and financial support for some programmes even where they have made progress in reversing the growth of STI and HIV related to sex work. 3.2 Participant recommendations to countries

3.2.1 Countries should seek every opportunity to begin or expand the reach of effective evidence-based targeted prevention interventions for sex workers, their regular partners and their clients, such as but not limited to the 100% CUP, which are adapted to fit local, political, cultural and epidemiological circumstances. In this effort, countries should pay particular attention to: (I) assuring strong political support from national to local levels;

(2) ensuring multisectoral participation in all aspects of the programme design and implementation and especially to assure close working relationships with public security, sex business owners and managers, sex workers and other gatekeepers; (3) paying attention to the need to protect the legal and human rights of sex workers and their clients and partners, especially as they may relate to access to quality care; (4) involving sex workers in all aspects of the design and implementation of the programme; (5) strengthening monitoring and evaluation activities to ensure "No condom, No sex" in sex work; (6) assuring that it is not a "stand-alone programme" but is fully incorporated into and consistent with the national response to HIV/AIDS, the national strategic health and other such relevant plans; and, (7) taking advantage of every opportunity to mobilize national funding and support from public, private and nongovernmental sources. 3.2.2 When designing and implementing new or expanded HIV and STI prevention programmes for sex workers, including the 100% CUP, countries should ensure that the programmes are not only addressing the promotion and availability of high-quality condoms in places where sex is negotiated or conducted, but also promoting safer and healthier sex practices including condom use in high-risk sexual encounters. It will be especially important that the programme's monitoring and evaluation systems are designed to focus on programme coverage, outcomes and impacts.

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3.3

Participant recommendations to WHO and UNFPA

3.3.1 WHO and UNFPA should continue to work together and coordinate activities so as to support national governments in the design and implementation ofHIV and STI prevention in sex work including targeted condom use programmes. 3.3.2 WHO and UNFPA should advocate for support of effective, evidenced-based HIV and STI prevention programmes related to sex work, including the 100% CUP where relevant, in international forums and among national governments and funding agencies. 3.3.3 WHO and UNFPA should develop technical documentation and providing technical assistance to countries in the areas of: (1) methods to incorporate essential strategic elements necessary for effective HIV and STI prevention in sex work including targeted condom use programmes that are consistent with the circumstances and the types of sex work confronted locally; (2) ways to more effectively reach out to and address the needs of all female, male and transgender sex workers, their regular partners and their clients, and to confront the public health issues surrounding international cross-border sex work and the correlation between drug use and sex work; (3) technologies and methods to monitor and evaluate the effectiveness and impact of HIV and STI prevention related to sex work including the 100% CUP; and, (4) strategies to advocate for long-term (financial and human) resource mobilization for the programmes to prevent HIV and STI transmission in sex work.

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ANNEX 1

PROVISIONAL AGENDA

I 2 3 4 5 6 7 8 9 10 II

Opening ceremony Objectives and organization ofthe meeting Viewing of poster set-up on sex work interventions Sharing of country experiences on sex work interventions Issues related to sex work Approaches to promote lIIV prevention in sex work Lessons learnt from external review Identifying strategies for scaling-up interventions Countries to identifY three to five key activities to be implemented immediately upon return Presentation, revision and adoption of draft conclusions and recommendations Closing ceremony

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ANNEX 2

LIST OF P ARTICIP ANTS, TEMPORARY ADVISERS, OBSERVERS, CONSULTANT AND SECRETARIAT 1. PARTICIPANTS

UNITED NATIONS POPULATION FUND (UNFPA) CHINA Ms Li Jia, Assistant Researcher, National Centre for AlDS/STD Control and Prevention, China CDC, 27 Nan Wei Road, Xianwie District, Beijing 100050. Tel No.: (8610) 63152573. Fax: (8610) 63131081. E-mail: ilyjiajiaau@yahoo.com.cn Ms Guo Wei, HIV Prevention Programme Specialist, UNFPA-China, 1-161 Tayuan Diplomatic Office Building, 14 Liangmahe Nanlu, Beijing. Tel No.: (8610) 6532 0506. Fax No.: (8610) 6532 2510. E-mail: guocw'unfpa.org Mr Guan Zhenhua, Project Officer, Department of Domestic Programmes, China Family Planning Association, # 35 Shaoyaoju, Chaoyang District, Beijing. Tel No.: (8610) 84657970. Fax No.: (8610) 84657979. Email: solarguanCW.gg.com Mr Song Vi, Programme Officer, International Department of China Contraceptive Supply and Development Center, No. 14 A, Zhao lun Miao Road, Haidian District, Beijing. Tel No.: (8610) 6211 6622 ext 3071. Fax No.: (8610) 6211 1977. Email: songyichina({llyahoo.com.cn PHILIPPINES Dr Jovanni Templonuevo, National Professional Programme Personnel for STlIHIV/AIDS, UNFPA, Philippines, 30th Floor, Yuchengco Tower I, RCBC Plaza, 6819 Ayala Avenue, 1229 Makati City. Tel No.: (632) 9010308. Fax No.: (632) 9010348. E-mail: jaytmplnv@yahoo.com; jtemplonuevo(iV.unfpa.org.ph

Caca Carillo, B.S.N.R.N., Provincial Project Coordinator, UNFPA TAP Office, Mabini St, Kalibo, Aldan. Tel No.: (036) 262 7981. Fax No.: (036) 262 7981. E-mail: unfpatap@cruznet.ph;boracacai(rv.yahoo.com Dr Amildo C. Tamayo, Officer in Charge, City Health Department, City Hall, Olongapo City. Tel No.: (047) 2241628. Fax No.: (047) 2224897. E-mail: tdizonCW.unfpa.org.ph VIET NAM Dr Dang Van Nghi, Vice Director of Population Department, Viet Nam Commission for Population, Family and Children, 12 Ngo Tat To street, Dong Da District, Ha Noi. Tel No.: 0903 234588; 7470371. Fax No.: 04 8438694. E-mail: Danvannghi(w,yahoo.com

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Annex 2 WHO-WESTERN PACIFIC REGION CAMBODIA Dr Lan Van Seng, Deputy Director, National Center for HIV/AIDS Dennatology ,and STD (NCHADS), No.170 Preah Sihanouk Boulevard, Phnom Penh. Tel No.: (85512) 847846. Fax No.: (855 23) 216515. E-mail: lanvanseng@nchads.org;lanvanseng(iiJ.evcryday.com.kh Mr Kim Sitha, HIV / AIDS Programme Manager, AIDS/STI Office, Sihanoukville Health Department, Sangkat 4 Kihan Metapheap, Sihanoukville. Tel No.: (012) 849001. E-mail: paostdskv(u1yahoo.com Mrs Chou Bun Eng, Director-General, Ministry of Women's Affairs, Fonner Executive Director, Cambodian Women for Peace and Development Kolab I, Sras Chak Khan Daun Penh, Phnom Penh. Tel No.: (855 12) 12872639. E-mail: cheng(wyahoo.com CIDNA Dr Xiao Xianghua, Supervisor, Hubei Provincial Health Department No. 165 Eastlake Road, Wuhan, Huhei 430071. Tel No.: (027) 87311446. Fax No.: (027) 87824785. E-mail: hbwswsCw.hbws.gov.cn Dr Sun Changsong, Vice-Director-General, Huhei Provincial Health Department, No. 165 Eastlake Road, Wuhan, Hubei 430071. Tel No.: (027) 87824785. Fax No.: (027) 87824785. Dr Jia Manhong, Section Chief, Yunnan Center for AIDS Prevention and Control, Yunnan Center for Disease Prevention and Control, No, 158 Dongsi Street, Kunming, Yunnan,_Tel No.: (86 871) 3623294 and 3614700. Fax No,: (86 871) 3623294 and 3614700. Email: jmanhong@yahoo.col11.cn GUAM Mr Baltazar B. Aguon, Health Educator, Department of Public Health and Social Services, 123 Chalan Kareta, Rt 10 Mangilao, Tel No.:_(671) 735 7402 and 7403. Fax No,: (671) 7357404, E-mail: TstMAGI@gmai1.com Mr Timmy C. dela Cruz, Vice President-Board of Directors, Guam HIV/ AIDS Network-GUAHAN Project, P.O, Box 20640, GMF Barrigada. Tel No.: (671) 647 5684 and (671) 472 6025. Fax No,: (671) 647 5684 E-mail: timik(mguam.net KIRIBATI Ms Mamao Robate, Principal Nursing Officer, Ministry of Health and Medical Services, TCH, Navesevese, Tarawa. Tel No.: (686) 28100. Fax No.: (686) 28152. E-mail: mrohate(diyahoo.com Mrs Maoto Metai, Coordinator, Adolescent and Reproductive Health, Ministry of Health and Medical Services, P.O. Box 268 Bikenibeu, Tarawa. Tel No.: (686) 28493 (home) 25487 (office). Fax No.: (686) 28501128152. E-mail: ahdbetio(ti)tskl.net.kir LAOPDR Dr Phouthone Southalack, Deputy Director, Centre for lIIV/AIDS/STI (ClIAS), Ministry of Health, KM3 Thadeua Road, Ban Phoxay, Sisattanak District Vientiane Capita\. Tel No,: (85621) 315500, Fax No,: (85621) 315500 E-mail: ptsout@yahoo.com

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Annex 2 Dr Bongsouvanh Phanthavongsa, Chief of Technical Office, Provincial Health Department, Secretariat ofMBDS Project, Savannakhet. Tel No.: (856 41) 253295. Fax No.: (85641) 214095; 253295. E-mail: bongsouvanh@hotmail.com Mr Sythong Nouansengsy, Marketing Director, Populations Services International-Laos, P.O. Box 8723, Vientiane Capital. Tel No.: 0205517926. Fax: (85621) 313512. E-mail: psilaos@laopdr.com; nsythong(lV,laopdLcom

MALAYSIA

Dato' Dr Faisal b Hj Ibrahim, HN and Drug Use Program Manager, Disease Control Division (AIDS/STI), Ministry of Health, AIDS/STD Section, Ministry of Health, Level 4 Block E I 0, Parcel E, Federal Govenunent Administration Complex, 62590 Putrajaya. Tel No.: (603) 88834387. Fax No.: (603) 88834285. E-mail: faisal@,dph.gov.my; uatofaisalpj(al.yahoo.co!."!:! Dr Rohani bt Ali, Senior Principal Assistant Director, AIDS/STD Section, Disease Control Division, Ministry of Health, Level 4 Block ElO, Parcel E Federal Government Administration Complex, 62590 Putrajaya. Tel No.: (603) 88834387. Fax No.: (603) 88834285. E-mail : rohani(l/ldph.goV.lill'

MONGOLIA Dr Jigjidsuren Nyamjav, Head of AIDS/STI Department, National Center for Communicable Diseases, NCCD Campus, Nam Yan Ju St., Bayanzurkh District-14, Ulaanbaatar-48. Tel No.: (976-11) 458787. Fax No.: (976-11) 458787. E-mail: J nyamjav@yahoo.com

Dr Chultem Baigalmaa, Medical Officer, AIDS/STI Department, National Center for Communicable Diseases, NCCD Campus, Nam Yan Ju St. Bayanzurkh District-14, Ulaanbaatar-48. Tel No.: (976 II) 462421. Fax No.: (97611) 458787. E-mail: ch baigalmaa9541@lyahoo.com Mr Delegchoimbol Amarsaikhan, Chief of Police Department of Orkhon Province, Bayantsagaan bag, Bayan Undur sum, Orkhon Province, Tel: (976) 1352-21324. Fax: (976) 1352-22616. E-mail : AmraasanClllyahoo.l;Oll1 PHILIPPINES Dr Emesto Eusebio S Villalon Ill, Medical Specialist II, Center for Infectious Diseases, National Center for Disease Prevention and Control, Bldg.13, Department of Health, San Lazaro Compound, Sta. Cruz, Manila. Tel No.: (63) 91976117156. Fax No.: (675) 3013742. E-mail: erisusa@hotrnail.com nd Dr Godofredo Relloraza, City Health Officer I, City Health Office, 2 Floor Marcos Building, San Fernando City, La Union. Tel No.: (072) 888 6916. Dr James Nicholas C. Piad, Secretariat Staff, Philippine National AIDS Council, 3'd Floor Building 12, Department of Health, Sta Cruz, Manila Tel No.: (632) 7430512; 3386440. Fax: (632) 743 0512. PAPUA NEW Mr Lindsay Piliwas, Director, Health Promotion, Department of Health, GUINEA P.O.Box 807, Waigani, Port Moresby. Tel No.: (675) 301 3692. Fax No.: (675) 3013742. E-mail: Lindsay piliwas@health.gov.pg Dr Joachim Pantumari, Senior Medical Adviser, National AIDS Council Secretariat, Heduru House, P.O. Box 1345, Boroko. NCD. Tel: (675) 3236161. Fax No.: (675) 323 1619. E-mail: jpantumari(tVllacs.org.pg

- 26-

Annex 2 Mr Gilman Ivana, Coordinator, Settlement Awareness and Condom Distribution, Anglicare StopAIDS PNG, P.O. Box 6491, Boroko, NCO. Tel No.: (675) 3251855. Fax No.: (675) 3251103. E-mail: acpngpom(?v.global.net.pg FIJI

Dr Mike Kama, Medical Officer, STI Clinic, Rodwell Road, Suva. Tel No.: (679) 3319144. Fax: (679) 3319145. E-mail: mikekarmer(a!yahoo.co.uk Mr Michael Sami, Sales and Marketing Manager, Marie Stopes International Pacific, Condom Social Marketing Project, Private Mail Bag, Suva. Tel: (679) 3317459 mobile: (67) 9279136. Fax: (679) 3317455 E-mail: Michael.sami({v.mariestopes.org.fj

VIET NAM

Dr Nguyen Huu Hung, Deputy Director, Preventing HlV in Viet Nam Project, 7 th Floor, 14 Lang Ha Badinh, Ha Noi. Tel No.: (844) 772 3063. Fax No.: (844) 772 3063. E-mail: huuhun!,1J11oh(al.yahoo.col1} Ms Duong Thi Kim Anh, Officer, PA23 of People's Public Security Headquarter, Hatay Province. Tel No.: (034) 889090. Fax No.: (034) 822 790 Ms Tran Thi Bich Hau, Hatay's Center, HlV/AIDS Prevention, N 80 Q Wuang Trung, Hadong District, Hatay Province. Tel No.: (844) 034 551082. Fax No.: (844) 034 551082. E-mail: tranbichhau(iil,yahoo.com WHO/SOUTH-EAST ASIA REGION

BHUTAN

Dr Gampo DOIji, Programme Manager, Department of Public Health, Ministry of Health, Thimphu. Tel No.: (975) 2322602. E-mail: gampo73@yahoo.com

INDONESIA Dr Nurhalina Afriyana, Staff-Sub-Directorate, HIV/AIDS and STI Focal Point for 100% Condom Use, Directorate ofDTDC, Ministry of Health, Jakarta. Tel No.: (6221) 42880231. Fax No.: (6221) 42880231. E-mail: afriananurhalina(i"i)yahoo.co.id

Dr Achmad Djaeli, Chief Sub-Directorate, CDC in Provincial Health Office of East Java, Surabaya. Tel No.: (6231) 8280650. Fax No.: (6231) 8280650. E-mail: djaeli02({v.yahoo.com MYANMAR

Dr Nyan Tun, State AIDS/STD Officer, State Health Department, Taunggyi Shan State (South). Tel No.: (9851) 21257 (office); 95-9-5210720. E-mail: htun.nyan({l{gmail.com Dr Mahinda Perera, Medical Officer, STD General Hospital, BadulJa. Te No.1: (94) 55 2222578; 552229572. Fax No.: (94) 55 2229572. E-mail: kmahinda@.hotmai1.com Dr Pachara Sirivongrangson, Medical Officer / Chief of STI Cluster, Bureau of AIDS, TB and STI, Department of Disease Control, Ministry of Public Health, Bangkok. Tel No.: (662) 2863263. Fax No.: (662) 2873553. E-mail: sirivong(lv.health.moph.go.th;pasirivong(ci!yahoo.com

SRI LANKA

THAILAND

- 27 -

Annex 2

2. TEMPORARY ADVISERS Ms Keo Tha, Director, Women Network for Unity, No.1 Street Sisowath, Sangkat Srasschork, Phnom Penh, Cambodia. Tel No.: (855) 12 471093. E-mail: womensnetworkCw,womynsagenda.org Ms Khartini Slamah, Coordinator, Asia Pacific Network of Sex Workers (APNSW), No. 276B, Batu 2 y., lalan Ipoh, 51200 Kuala Lumpur. Malaysia. Tel No.: (603) 4041 8966. Fax No.: (603) 4041 8966. E-mail : apnswCtilyahoo.com Dr Teodora Elvira Wi, Director, STI Capacity Building, Family Health International-India, 501-505, Balarama Building, Bandra Kur1a Complex, Bandara East, Mumbai 400 051 ,India. Tel No.: (91 22) 5675 0457/26592350/2. Fax No.: (9122) 2659 2344. E-mail : twi(aJfhiindia.org 3. CONSULT ANT Dr Robert Fischer, 3/39 Shanti Niketan, New Delhi 21, India. Tel No.: (91-11) 2412-1929. Email: drbobfischerisCw.hotrnail.com

3 OBSERVERS/REPRESENTA TIVES DKT International Mr Michael Uy Santos, Product Manager, DKT Philippines, Suite 801 Linden Suites, 37 San Miguel Avenue, Ortigas Center, Pasig City Philippines. Tel No.: 09l78231766. E-mail: msantosuv,frenzy.colll,nb Dr Loreto Roquero Jr, Philippine Country Director, Family Health International, Department of Health, Building 3, Ground Floor, San Lazaro Compound, Santa Cruz, Manila 1003,Philippines. Tel No.: (632) 338 7464. Dr Ma. Elena F. Borromeo, UNAIDS Country Coordinator, 311F Yuchengco Tower, RCBC Plaza, 6819 Ayala Avenue, Makati City, Philippines. Tel No.: (632)901-0412; 901-0411; 889-7414. Fax No.: (632) 901-0415. E-mail: ma.elena.borromeo(ill.lIndp.org. Dr John Eyres, Senior Technical Advisor for HIV Prevention, U.S. Agency for International Development, #2 Ngo Quyen Street 151F, Ha Noi, Viet Nam. Tel No.: (844) 935 1244. Fax No.: (844) 935 1265. E-mail: jeyres@lIsaid.gov 5. SECRETARIAT UNFPAlCST Bangkok Dr Chaiyos Kunanusont, HIV / AIDS/STI Adviser, UNFP NCSTBangkok, United Nations Population Fund, 12th Floor United Nations Building, Rajdamnern Nok Avenue, Bangkok, Thailand. Tel No.: (662) 2881476. Fax No. (662) 2802715 E-mail: kllnanllsont.lInescapCtilllll.org Dr Setareki Vatucagawa, Reproductive Health Commodity Security Manager, UNFPA Office for the Pacific, Private Mail Bag, Suva, Fiji. Tel No.: (679) 3308022. Fax No.: (679) 331 2785. E-mail: svatucawaga(iv.lInfpa.org.fi

Family Health International

UNAIDSPhilippines

USAIDVietNam

UNFPAlCST Fiji

- 28-

Annex 2

UNFPA/CST- Dr Farah Usmani, Adviser-HIV I AIDS and Reproductive Health Nepal CST for South and West Asia, United Nations Population Fund Kathmandu, Nepal. Tel: (977) 1-5523880. Fax: (679) 1-5527257. E-mail: fusmani«i)unfpa.org.np UNFPAViet Nam Ms Akiko Takai, Programme Coordinator on HIV / AIDS, United Nations Population Fund-Viet Nam, UN Apt. Building, 2E Van Phuc Compound, Ha Noi, Viet Nam. Tel No.: (844) 823 6632 Fax: (844) 823 2822 E-mail: takai@unfua.org.vn Dr Bernard Fabre-Teste (Responsible Officer), Regional Adviser, Sexually Transmitted Infections including HIV/AIDS (HSI), World Health Organization, Regional Office for the Western Pacific United Nations Avenue, 1000 Manila, Philippines. Tel No.: (632) 528 9714. Fax No.: (632) 521 1036 E-mail: fabretesteb@wpro.who.int Ms Gaik Gui Ong, Technical Officer, HSI Unit, World Health Organization, Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Tel No.: (63 2) 528 9718. Fax No.: (632) 521 1036. E-mail: ongg(a)wpro.who.int Dr Nguyen Thi Thanh Thuy, Scientist/Epidemiologist, HSI Unit, World Health Organization, Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Tel No.: (632) 528 9717. Fax No.: (632) 521 1036. E-mail: thuyn@wpro.who.int Mr William Mfuko, Technical Officer-AMDS, HSI Unit, World Health Organization, Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Tel No.: (63 2) 528 9719. Fax No.: (63 2) 521 1036. E-mail: mfukow@wpro.who.int Ms Manuela Moller, Technical Officer, Harm Reduction, HSI Unit, World Health Organization, Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Tel No.: (63 2) 528 9759. Fax No.: (632) 521 1036. E-mail: moellermCti),wpro.who.int Mrs Anjana Bhushan, Technical Officer, Poverty and Gender, Health Care Financing, World Health Organization, Regional Office for the Western Pacific, United Nations Avenue, 1000 Manila, Philippines. Tel No.: (63 2) 528 9814. Fax No.: (63 2) 521 1036. E-mail: bhushana(iilwpro.who.int Dr Wiwat Rojanapithayakorn, Senior Adviser, Comprehensive HIVI AIDS Prevention, Care and Treatment, World Health Organization, 401, Dongwai Diplomatic Office Building, 23, Dongzhimenwai Dajie, Chaoyang District, Beijing 1000600, China. Tel No.: (8610) 6532 7189 to 92. Fax No.: (86 10) 6532 2359. E-mail: wiwatr({v,chn.wpro.who.int

WHO WPRO

- 29-

Annex 2

Dr Zhao Pengfei, Senior Programme Officer, HIV/AIDS, World Health Organization, 401, Dongwai Diplomatic Office Building, 23, Dongzhimenwai Dajie, Chaoyang District, Beijing 1000600, China. Tel No.: (8610) 6532 7189 Fax No.: (86 10) 6532 2359. Email: zhaopfCti1c1m.wpro.who.int Dr Ahmed Zouiten, Medical Officer, HIV/AIDS and ST!, World Health Organization, Ban Phonxay, That Luang Road, Vientiane, Lao People's Democratic Republic. Tel No.: (8560) 21413 431. Fax No.: (856 0) 21413 432. E-mail: zouitena@lao.wpro.who.int Dr BalanVenugopalan, HIV/AIDS Focal Point, World Health Organization I st Floor, Wisma UN, Blc C, Komplek Pejabat, Damansara, jalan Dungun, Damansara Heights, 50490 Kuala Lumpur, Malaysia. Tel No.: (603) 209 39908. Fax No.: (603) 209 37446. E-mail: venugopalanbCti1maa. wpro. who.int Dr Jadambaa Narantuya, Project Officer, CSR, TB and HIV/AIDS, World Health Organization, Ministry of Health, Government Building-8, Ulaanbaatar, Mongolia. Tel No.: (976) 11 327870. Fax No.: (976) 11 324683. E-mail: NarantuyaJ@mog.wpro.who.int

Dr Agatha Lloyd, Medical Officer (ART Specialist), World Health Organization, P.O. Box 5896, Boroko, NCD, Papua New Guinea. Tel: (675) 325 7827. Fax No: (675) 325 2035. E-mail: lIoydaCtl!,png.wpro.who.int Dr Nerissa Dominguez, Project Coordinator, World Health Organization National Tuberculosis Centre Building, Second Floor, Bldg. 9, Department of Health, San Lazaro Hospital Compound, Sta Cruz, Manila, Philippines. Tel No.: (632) 338 7479. Fax: (632) 731 3914. E-mail: domingueznCtl!,phLwpro.who.int Dr Dominique Ricard, Medical Officer, HIV/ AIDS and ST!, World Health Organization, 63 Tran Hung Dao Street, Hoan Kiem District, Ha Noi, Socialist Republic of Viet Nam. Tel No.: (844) 943 3734. Fax No.: (844) 943 3740. E-mail: ricardd@vtn.wpro.who.int WHOIHQ

Dr Joseph Perriens, Coordinator a.i., HN Prevention in the Health Sector HN Department, Avenue Appia 20, CH-1211 Geneva 27, Switzerland. Tel No.: (4122) 7914456. Fax No.: (4122) 7914834. E-mail: perriensj@who.int

WHO/SEARO Mr Richard Steen, Focal Point for HIV/AIDS and ST!, Department of Communicable Diseases, World Health Organization, Regional Office for South-East Asia, World Health House, Indraprastha Estate, Mahatma Gandhi, New Delhi 110002, India. Tel No.: (91 11) 23370804. Fax No.: (91 11) 233 70197, E-mail: steenr@searo.who.int

- 31 ANNEX 3 COUNTRY POSTERS CAMBODIA Epidemiology ofHIV/AIDS in Cambodia After the first cases of HI V and AIDS were detected in 1991 and 1993 respectively, Cambodia was faced with a rapid increase of HIV prevalence. Cambodia has been ranked highest among countries faced with the HIV epidemic in Asia with HIV prevalence among the general population that peaked at 3.0% in 1997. The National AIDS Programme identified that the major route ofHIV transmission was heterosexual contact, with a spread ofHIV from high-risk groups, especially sex workers to low-risk groups such as housewives, through the bridge population of men who were clients of sex workers. In 1997, the HIV prevalence among brothel-based sex workers peaked at 42.8% and the HIV prevalence among the police peaked at 4.5%. Types of sex work in Cambodia Sex work is well organized in Cambodia. Sex industry includes brothel-based sex work involving so called direct sex workers (DSW) and indirect sex work at beer gardens (beer promotion girls), karaoke and massage parlors. Brothel-based sex work has slightly decreased over time with 6002 DSW identified in 1997 and 4663 in 2005. However, indirect sex work has spread dramatically from 5309 IDSW identified in 1997 to 17 706 in 2005. Geographical mobility in sex work is high and movement between direct and indirect sex work is bidirectional. Condom Promotion in Sex Works In 1998, the 100% condom use policy was adopted to prevent the spread of HIV infection and started with a pilot project in Sihanouk Ville. In 2000, a National Policy on 100% Condom Use was declared for country-wide implementation.

3.1 • • • •

Objectives of the 100% CUP Ensure 100% condom use in all sexual entertainment services Ensure that brothel-based sex workers and non-brothel based sex workers have access to regular STI services Promote condom use for brothel and non-brothel-based sex workers Ensure outreach and peer education to support condom use for high risk popUlations

3.2 • • •

Strategies of tile 100% CUP Ensure geographical coverage. Work with PSI (social marketing of condoms) to ensure condom availability. Involve brothel owners and local government authorities to enable sex workers to systematically use condoms with every client and to attend specialized STl clinics every month for a check up. Strengthen provincial outreach teams (POT) in managing and coordinating outreach and peer education programmes for high-risk populations. Establish an intervention package on prevention for non-brothel-based sex workers. Periodically assess and evaluate BCC programmes.

• • •

- 32Annex 3

3.3

Coverage (target groups, geographical, services)

After the start of a pilot project in 1998 in Sihanouk ville, the 100% CUP was scaled up to 4 provinces in 2000, 10 provinces in 2001, 15 provinces in 2002 and 22 provinces up to 2006. From 1998 to 2002, the programme focused on brothel-based sex workers. From 2003, the target groups included non-brothel based sex workers. Programme activities included regular mapping of sexual establishments and census of sex workers, condom social marketing, outreach activities at brothels with HIV/AIDS education and condom promotion, peer education, provision of free monthly examination and STI treatment at "user-friendly" STI clinics for sex workers.

3.4

Achievements and impact

The impact of the 100% CUP was evaluated over time with regular HIV Sentinel serosurveillance (HSS) and Behavioral Sentinel surveillance (BSS) among sex workers, police and general population. Surveillance data over time showed that the 100% CUP has contributed to a sharp decrease in STI and HIV prevalence among sex workers and their clients (Figure 1, 2). From 1998 to 2003, the rate of condom use of DSW with clients increased from 53.4% to 96% and the HIV prevalence among DSW decreased from 42.8% to 20.8%. The HIV prevalence among the general population has decreased from 3.0% in 1997 to 1.9% in 2003.

120 100

__1_1-------

91.7

96

80

60 40 20

~20.8

o +-----.-----.-----.-----.-----.-----.-----.-----. 1996 1997 1998 1999 2000 2001 2002 2003

Figure 1: Impact of 100% CUP on condom use by brothel-based sex workers with clients alld HIV prevalence among brothel-based sex workers, Cambodia 1996-2003

- 33 Annex 3

100

90 80 70 60 50 40 30

'1iill==jft94.2 86.9 ~

.4

20 10 0

1997

1998

1999

2001

2003

I~Moto-taxl -@-Milltary ...... Police

I

Figure 2: Impact 100% CUP on condom use by men with sex workers in past 3 months. Cambodia /997-2003

3.5

Key lessons leamt

The 100% CUP has contributed to control the HIV epidemic in Cambodia. The specificities of the Cambodian 100% CUP that contributed to this SUCcess were: • Strong political support from policy makers and commitment from local authorities and police. • Empowennent and engagement of sex workers to negotiate with clients. • Establishment of consistent condom use as a norm in sexual entertainment services, enforced by brothel owners. Overall, sex workers, clients and brothel owners viewed the 100% condom use policy as a necessity rather than a threat.

3.6

Future plan towards nationwide scale-up

The 100% CUP was externally reviewed in 2003. The main output of the review was a set of recommendations for strengthening the 100% CUP. These recommendations were addressed as follows: • • • • • Human rights group included in condom use coordination committee (CUCC). Involvement of SW representative in national and provincial committee. Clear TOR established for Condom Working Group in June 2006 (SOP). Clients are more targeted (increased coverage of intervention with police. Outreach and peer education programme. ~ New SOP for outreach and peer education (OP) programme ~ More involvement ofNGOs doing outreach/peer education (OP) ~ Expansion ofOP to non-brothel based SW (IDSW) ~ Social intervention for SW included into outreach programme sessions

- 34Annex 3

• • •

Twenty Nine STI clinics currently equipped with laboratory support (15 fully functioning). Refined algorithms for STI syndromic management. Improved links with VCCT and care and treatment services including OlJART through the continuum of care (CoC).

The future plans for the programmes are to: • • • • • • • Maintain political support. Maintain outreach interventions to brothel-based and non-brothel-based sex workers. Maintain availability of condoms by collaborating with PSI. Maintain drug, equipment and human resources for STI case management. Improve coverage and intervention package for non brothel-based sex workers. Active involvement from local authority. Investigate the best approach for intervention to improve condom use with sweetheart.

- 35 -

Annex 3 CHINA

TYPES OF SEX WORK AND ESTIMATED NUMBER OF SEX WORKERS BY TYPE

Currently, workplaces of sex workers (SWs) in China include hotels, hostels, rest houses, spa centres, clubs, bars, karaoke, beauty and hair saloons, sauna centres, massage parlours, foot massage parlours, roadside inns and street-based sex service, etc. By the end of March 2006, the reported number of SWs across the nation was around 1.03 million, the real figure should be much larger. Due to high mobility of this population group, the national figure for the size of establishment-based sex workers are not available at present. CONDOM PROMOTION IN SEX WORK ~

Strategies Used and Current Status

In recent years, HN transmission through unsafe sex has been increasing. The Chinese Government has placed considerable emphasis on HIV/AIDS prevention and control. A series of policies, statutes and papers have been promulgated and brought into effect, to prevent and control sexual transmission of HlV. In July 2004, "Notions on Condom Use Promotion for HIV/AIDS Prevention" (MOH [2004]248) was jointly promulgated by six sectors, including the Ministry of Health, the State Population and Family Planning Commission, the State Food and Drug Administration, the State Administration for Industry and Commerce, the State Administration of Radio Film and Television, as well as the General Administration of Quality Supervision, Inspection and Quarantine. It states the roles and responsibilities of the six sectors in condom use promotion. It requires that coverage of condom provision networks should be expanded, and accessibility of condoms should be improved. Given that interventions among high-risk groups are tremendous task which is normally accompanied with difficulties, "Announcement on Establishing Special Working Teams for Interventions among High-risk Groups in Centres for Disease Control and Prevention at All Levels" (MOH [2004]129) was promulgated by Ministry of Health in August 2004. It requires that a special working team for interventions among high-risk groups has to be established in each CDC at any level all over China. SWs and MSM (men who have sex with men) are major target groups for those special working teams. To provide guidelines for interventions at local level, in May 2005, "Guidelines for Interventions Targeting High-risk Behaviours" (MOH [2005]102) was promulgated by the Ministry of Health. The guidelines state that "to promote proper use of condom" is one of the major interventions targeting high-risk behaviours. The key population group for the intervention is SWs in entertainment sites, restaurants, hostels and street-based sex service. Meanwhile, it requires that comprehensive interventions, such as health education on HIV/AIDS prevention, condom use promotion, encouragement on receiving diagnosis and treatment services for STD and reproductive health services, and so on, should be implemented through outreach, peer education programmes and other ways. On I March 2006, the State Council promulgated "AIDS Control Statutes" (State Council 457). It regulates that governmental organizations at country and other levels, including health, population and family planning, business and commerce administration, food and drug administration, etc., should promote condom use, and establish and improve condom provision networks. Violators of this statute would be sanctioned to different degrees, such as circulating notice of warning, administrative disciplinary action or even being prosecuted. It also regulates that: operators of entertainment sites should place condoms or condom vending machines/equipment at the sites; SWs at entertainment sites should receive physical examination regularly and carry with them health proof certificates; those without certificates should not be permitted to work at entertainment sites. Violators of this statute would be sanctioned to different degrees, such as warning, penalties, remedy within a fixed period of time, cease of operation and revoking business license.

- 36 Annex 3

In addition to the increasing policy support, the Chinese Government has been enhancing financial support for mtervenhons among hlgh-nsk groups, and coverage of interventions has been gradually expanded (see Graph I). In 2003, the funding for "condom use promotion" which was transferred from the Central to the local reached RMB 42 .12 million, covering 351 cities/counties nationwide. Tn 2004, the fundmg transferred reached RMB 45.29 mill ion, covering 647 cities/counties. In 2005 the fundmg transferred reached RMB 59.64 million, covering 1327 cities/counties. In 2006 (h~ amount of fundmg and the coverage of cities/counties nationwide increased again. Beside~ the mcreasm? mput of the Central Government, local governments also increased their financial contrlbuhon to mtervention efforts among SW s.

Central Funding and Coverage of Cities/Counties for Condom Use Promotion 2003-2005 70 60 50 40 30 20 10 0 2003 2004 Ye ar _ _ Funding from the C e nlral

I = :s

I

1400 1200 1000 800 600 400 200 0 2005

~

I is

!

--+- Cities /Counties

Covered

Graph 1. Central Funding and Coverage o/ Cities/Counties/ or Condo", Use Promotion 2003-2005

»> Coverage (Target Group, Geographical and Services) According to data from the first quarterly report in 2006 on basic infonnation of interventions targeting high-risk behaviours, the number of SWs covered by interventions reached around 270 thousand by the end of March 2006, bringing the coverage rate to about 26% all over China. By 2005 , four Provinces (Hubei, Yunnan, Sichuan and Hainan) have reached provincial wide coverage of condom promotion programmes. Hunan, Xinjiang, Guizhou, Shanxi, Jiangsu and other Provinces have also implemented condom use promotion programmes at large scale. Intervention models include: I. Using STT clinics as platforms to provide clinic based outreach services: health workers directly go to workplaces of SWs to promole condom use and to provide counselling services on STI and female reproductive health care, offering face-to-face service among target groups. This helps increase accessibility and use of condoms as well as STI and reproductive health services. 2. Peer education: taking advantage of peer pressure to implement health education programmes on HIV/ AIDS prevention and to provide behavioural interventions services among target groups.

- 37 -

Annex 3

100% condom use programmes (100% CUP): since 2001, World Health Organization supported Ministry of Health to pilot 100% CUP in four provinces, including Huangpi District, Wuhan in Hubei, Jingjiang City in Jiangsu, Danzhou City in Hainan and Li County in Hunan, which had achieved effective results. National expansion of the 100% CUP is now underway in China, following an address from Vice Premier Madam Wu Yi in her speech at the State Council AIDS Working Committee Meeting in April 2004 for the urgent expansion of 100% CUP. Scaling up of the 100% CUP has been supported primarily through existing HN /AIDS prevention and care programmes, including China CARE, The Global Fund to fight AIDS, Tuberculosis and Malaria, China's National Tax Rebate programme, and other multilateral and bilateral projects. So far, 20 of China's 31 provinces are implementing the 100% CUP, with provincial-wide coverage achieved in Hubei (97 counties/districts) and Hainan (17 sites), and relatively large-scale coverage achieved in Hunan (66 sites), Sichuan (47 sites), Shanxi (25 sites), Jiangsu (22 sites), and Guizhou (22 sites). Provinces/autonomous regions with 1 to 10 sites each include Xingjiang, Gansu, Yunnan, Chongqing, Heilongjiang, Fujian, Beijing, Shandong, Liaoning, and Henan, Anhui, Shaanxi. In addition, UNFPA is funding five sites in five provinces, and Global Fund Round 3 has been implementing 100% CUP in its 58 project sites in six provinces since 2005. Since 2006, Global Fund round 4 and 5 projects on AIDS are gradually implementing the CUP in their project sites (some 100 sites in total) (Figure 1).

Figure 1. Provinces have been implementing 100 % CUP at various scale in China

- 38 -

Annex 3

Women health centres: target groups participate in all kinds of health education activities on HIV/AIDS prevention in those centres. 3. Interventions among long distance truck drivers: health education and interventions on HIV/AIDS prevention are conducted in truck terminals and stations for truck drivers to improve their knowledge on !-IIV/AIDS and to increase accessibility of condoms in this population group. 4. Interventions among sex workers at road side inns: outreach services, such as condom provision and counselling, are offered to sex workers to increase condom use rate in this group. ~

Achievement and Impact

National sentinel surveillance data shows that the rate of consistent condom use at every commercial sex among SWs increased from 14.7% in 2001 to 38.7% in 2005. The rate of never use during commercial sex decreased from 37.4% in 2001 to 10% in 2005 (See Graph 2) .

Impact of Condom Use Promotion (National Sentinel Surveillance Data) 40% 35% 30% 25% 20% 15% 10% 5% 0% 2001 2005

• condom use every time having commercial sex • never use condom In commercial sex

Graplr 2 Impact of Coltdom Use Promo/jolt be/weelt 2001 altd 2005 ~

Key Lessons Leamt which creates a supportive environment for HIV/AIDS prevention and control.

1. Coordination and cooperation across different sectors at all levels have been greatly enhanced,

2.

100% CUP is feasible, effective and replicable at large scale of coverage in China context.

3. Special working teams for interventions targeting high-risk groups have been established, which ensure effective implementation of interventions in terms of human resources.

- 39Annex 3

4. Coverage of interventions is limited, which is still inadequate to control HIV/AIDS epidemic through unsafe sex. 5. Number of local health staff for interventions is still inadequate, which influences effectiveness of interventions. 6. Capability oflocal health staff in providing comprehensive HIV/AIDS prevention services should be further enhanced. 7. There is lack of scientific evaluation on effectiveness of interventions. ~

Future Plan Towards Nationwide Scale-up

In March 2006, the State Council promulgated "China's Action Plan for Retaining HIV/AIDS Epidemic (2006-2010)" (State Council [2006]13) - the second five year action plan. The set target for condom use rate among high-risk groups is to reach 70% or above by the end of 2007; and 90% or above by the end of 2010. To fulfill these goals. the Chinese Government continues to increase financial support and expand intervention coverage among high-risk groups to effectively curb HIV/AIDS epidemic. Simultaneously, the Chinese Government is committed to fulfill the goal "Towards universal access to HIV, prevention, treatment, care and support by 2010". In line with the enforcement of the recently promulgated "China AIDS Regulation", technical assistance will be continuously sought from WHO and other agencies to increase coverage and ensure good quality of the national expansion of 100% CUP in China.

- 40Annex 3 THE REPUBLIC OF FIJI ISLAND

Couutry Profile Fiji is a South Pacific country that lies approximately 3000 Ian North-East of Sydney (Australia), comprising of two main islands and 300 smaller outlying islands, having a total land area of 18000 sq. Ian. In 2003, the population was estimated to be 868 531 providing a population density of 48 persons/Ian. The population is divided, almost evenly, between the indigenous Fijians (49%) and those of Indian descent (46%), with a small community of ethnic Chinese, Europeans, and other Pacific Islanders. The prominent religions are Christianity and Hinduism. Sixty four percent of the population is in the 15-64-age category, whilst the elderly (65years+) comprise 4%. About 48% of the population resides in the urban localities of the country. In 2003, Fiji's GOP was US$2.2 billion with a GOP per capita of US $2,703. Fiji has a population life expectancy of 67.3 years with a population growth rate of 1.2%' The average number of children born per woman is 2.9 and the current birth rate is 22.91 birthsll 000. The mean age of marriage for women is 22. The crude death rate stands at 5.68 deaths/lOOO population while the infant mortality rate is 12.99 deathsl1 000 live births. Health Services Fiji's Ministry of Health provides free (tax-based) or heavily subsidized public healthcare for its citizens. There are also medical and dental practitioners and pharmacists in private practice throughout the country, serving customers who have private health insurance or, those able to settle out-of-pocket payments. In 2001, the country's total health sector expenditure was 4% of GOP. The public health expenditure accounted for 67.1% of the total health expenditure whilst private health expenses accounted for the 32.9%. The universally utilized Government operated health service, is structured vertically and organized administratively into three geographical divisions (Central/Eastern, Western, and Northern divisions), 19 sub-divisions, 75 medical areas, and over 100 health zones. In 2000, the country's principle healthcare facilities comprised of three general hospitals (one in the urban capital of each division-200, 300, 450 beds), three specialist hospitals (for psychiatry, TB/leprosy, and physical rehabilitation), three nursing homes, 19 sub-divisional hospitals (20-80 beds), 75 health centers, and 100 nursing stations. The sum of all existing hospital beds provides a ratio of approximately 2-bedsll 000 population. The estimated numbers of key technical health personnel in 2001 are as follows: physicians47.61100 000 population, nurses- 195.11100000 population, and dentists- 4.31100 000 population. There is also a village health worker cadre, which is a non-formal part of government health services that is supported by the village leadership. Medical personnel tend to concentrate in urban areas, but even the more rural and remote areas are reasonably well served, relative to Pacific Island standards.

- 41 Annex 3

In 2000, the leading causes of inpatient morbidity and mortality were as follows: MORBIDITY (Rate per 100,000 population) Diseases of the respiratory system Diseases of the circulatory system In~ry and poisoning Diseases ofthe digestive system Infectious and parasitic diseases MORTALITY (Rate per 100,000 population) Diseases of the circulatory Infectious and parasitic diseases Diseases of the respiratory system Neoplasm Diseases of the genitourinary system

776.49 635.89 550.50 443.09 420.12

55.21 13.71 12.51 lI.I9 09.98

In 2003, morbidity trends remained unchanged whilst mortality trends recorded the following hierarchical changes: Circulatory diseases, injury and poisoning, neoplasm, infectious and parasitic diseases, and endocrine andlor metabolic disease. Health sector reforms and establishment of a Health Management Information System are the prioritized MOH corporate goals that are currently underway. This is to be facilitated through health care financing, decentralization of health services and capacity building of individual It was anticipated that further international managers and institutions in the country. collaboration would be required, during the 2002-2006 period, to refine the system operation. HIV and STI Situation

The first HIV case was diagnosed in 1989. Presently there are 219 HIV/ AIDS cases in Fiji. Data on HIV prevalence and AIDS cases are of questionable reliability. A WHO workshop conducted in 2005 arrived at an estimate of 590 HIV cases in the country. As of 2005, Fiji has an HIV prevalence of 0.0 1%. AIDS cases are however underreported. In 2005, a total of 29 AIDS cases were reported. STI's are prevalent in Fiji. An SGSS conducted in 2004 found that chlamydia, syphilis and gonorrhea were common among the sub-populations surveyed. Resistant strains of gonorrhea to antibiotic were estimated at 1.2%. The HIV epidemic in Fiji appears to be due primarily to heterosexual transmission mostly affecting the indigenous males. Commercial sex work is illegal however it has burgeoned and is driven largely by the climate of economic hardship present in the country. Fiji has a multi-sectoral National Advisory Committee on HIV that coordinates national strategies on HIV control and prevention.

Sex Work and Condom Use Sex work in Fiji is illegal. Sex workers in Fiji comprise primarily of women and trans-genders. The classification of sex workers in the country is as follows: 1. Professional Sex Workers: Comprise of Call Girls; those who work with hotels; and those with day jobs. These sex workers are mobile and operate from their home or work office.

- 42-

Annex 3

2. Middle Class Sex Workers: Comprise of sex workers that work in nightclub bars at night and operate from their homes or a motel during the day. 3. Low Class Sex Workers: Comprise of old and young sex workers that work the street at night and operate from specific geographical locations in the greater urban areas and its peripheries. Despite expanded national advocacy programmes on condom use over the past decade the condom use in the country is estimated at less then 20%. The rate of use of condoms amongst commercial sex workers is estimated at less than 5%. Fiji's public health system provides free standard brands of condoms for STI prevention for the general public from its three divisional STI sentinel clinic sites and national reproductive health centre (Oxfam clinic). Acquisition of condoms by commercial sex workers from these public health outlets is limited. The other levels of health care provide condoms primarily as a family planning device. From a secondary generation surveillance conducted in the country in 2005 it was estimated that less then 1% of the population used condoms on sex occasions. Nongovernmental organizations are more structured and proactive in the manner in which they advocate condom use to commercial sex workers. Various condom brands are available at their clinic sites that are easily accessible to sex workers nation wide. NGO providers also regularly mobilize these consurnables on the street at night distributing single packets to sex workers. These NGO's also make available condoms from popular motel sites from which sex workers operate. Provision of condoms to sex workers by these NGO's is estimated at 70%. A survey to estimate the use of condom among sex workers is yet to be undertaken. Apparently there needs to be multilateral consultation to develop a standard framework that would serve to strengthen and ensure equal access of condoms by the public and particularly sex workers, for STI and HIV prevention, from all public health outlets and NGO clinic sites.

- 43 Annex 3

GUAM Country Information An unincorporated territory of the United States, Guam is located in the Western Pacific and is the southernmost island of the Mariana Islands Archipelago. The total land area IS 212 square miles and the current population is 168 564 (July 2005 estimate). The indigenous population is called ChamoITos, whom as an ethnic group comprise 37.1 % of the population. The island also has a significant immigrant community from South-East Asia (mainly Filipinos) and from the Micronesian region (mainly nationals from the Federated States of Micronesia). Historically, Guam has been a transient outpost for US Military Personnel and predominantly Japanese tourists. Visitor arrivals far exceed the resident population, with approximately 1.2 million visitors annually. Types of Sex Work In March 2002, a total of 174 people indicated being employed at a strip bar on Guam. Of which 84 were female dancers, 35 female hostesses, 10 female owners, 6 female managers, and 32 male and female employees whose employment positions were listed as "other". The ethnic composition of all personnel employed at a strip bar on Guam: 41.4% Asian, 25.8% Caucasian, 20.7% Pacific Islander, and 1.2% Hispanic.!

Quarterly screening in Guam's Massage Parlor Worker (MPW) Industry, a regulation established since 1984, is a mandate issued by the Department of Public Health and Social Services. This mandate is to prevent and control STD outbreaks in the massage parlors and transmission to community. This mandate requires that massage parlor management ensures that its workers are tested and certified to be free of the following STls and HIV. In 2004, a total of 206 record reviews were conducted from 2000 to 2003. A summary of the records reflect that: 1) amajorityofMPWs are over the age of35; 2) MPWs have a low STD infection rate; 3) MPW screening visits are costly and not consistent with regulations. ESTABLISHMENT TYPE AND NUMBER OF FACILITIES ON ISLAND

Massage Parlors - 12 Karaoke Lounges -42 Strip Clubs -12 Shiatsu's/Therapeutic Massage - 20 Free LancerslHappy Hookers "TGs" - 15 Adult Video Book Stores (often frequented by freelance sex workers) - 7 Motels - (2 known motel in Hagatna with heterosexual and trans gender freelance sex workers) I Hill, A. (2002). Exotic Peiformances and Perceptions: The Position of the Strip Bar on Guam. Mangilao: University of Guam.

BP Schumann 2. (2004) Screening Massage Parlor Sex Industry Workers: How Often Should Sex Industry Workers Be Screened? Guam Department ofPublic Health and Social Service

- 44-

Annex 3

Condom Promotion in Sex Work STRATEGIES USED AND CURRENT STATUS

• • • • •

Massage Parlor Regulation of 1984 (quarterly screenings & condom reinforcement) Identified current hot spots where underground sex work takes place Public Health Outreach Workers distribute condoms to sex establishment locations that are known to have reported infections Condom distribution and promotion through Department of Public Health and Social Services prevention program - "Prutehi Hao" Free latex condoms available to all populations at Public Community Health Centers (3 locations), Guam HNIAIDS Network Project Office (1 location) and University of Guam Student Health Center (1 location)

COVERAGE (TARGET GROUP. GEOGRAPHICAL AND SERVICES)

• •

Coverage area includes Northern/Central villages known to have higher percentages of the target sex worker groups. Coverage area includes Underground Sex Entertainment Establishments with known highrisk behaviours.

ACHIEVEMENT AND IMPACT (E.G.% OF CONDOM USE BY SEX WORKERS AND OR CLIENTS)

• •

No data available The Guam Department of Public Health is currently monitoring outbreaks linked to Entertainment Establishments, Shiastu Therapeutic and Massage Therapy Clinics through the STIIHN Database Collection

KEy LESSONS LEARNT

•

Massage Parlors-aware that they have to comply with testing due to regulation and state that they practice compliance of 100% condom use during their Health Certificate renewal visits (data retrieved from the SHPP Database); STD infection low among a majority of the MPW who are over 35 years of age Information concerning "underground sex industry worker" unavailable Guam public law prohibits prostitution and sex work; due to fear of prosecution, population is difficult to penetrate Suspicions of existing "Asian" sex trade network on island, though substantiating data unavailable to confirm these claims (i.e., Recently during a television interview promoting their live performance at a karaoke lounge, a Philippine entertainment group publicly alluded on local television they did more than dancing. They were investigated on suspicion of prostitution and were subsequently arrested for visa fraud. A judge in Hawaii has since granted them voluntary departure to return to the PI).

• • •

- 45 -

Annex 3 FUTURE PLAN Tow ARDS NATIONWIDE SCALE-UP

• • • • • •

Review and implement timeframe and Social Mapping by WHO Technical Officer visit to Guam in April 2006 Public Health will continue to monitor STI outbreaks at various sex establishments Assess availability of HIV and STI services at sex establishments and Identify new sex establishments Lobby policymakers to adopt and implement standardslcertification of therapeutic massage parlors to include regulatory standards similar to 1984 Massage Parlor Regulations Increase HIV/STI prevention outreach to various massage industry/establishments and encourage 100% CUP participation Establish collaboration with US Military and explore potential health impacts to the local community as a result of the relocation of 8000 US Marine personnel from Okinawa to Guam; engage public health and military entities to develop greater working relationships and shared resources in efforts to implement 100% CUP DPHSS to partner with GUAHAN Project and various community-based organizations to implement 100% CUP; through collaboration, CBO will be encouraged to take the lead to establish ties and links with massage parlors, karaoke bars, and club owners CBO with support from Public Health Department will provide health education 100% CUP sessions and HIV/AIDS prevention education Key informants from the sex worker industry will be sought and encouraged to participate in 100% CUP Consider whether Second Generation STlIHIV Surveillance Survey be conducted to study prevalence of sex trade in Guahan. Presently, the SGS Study is being conducted to three identified targeted populations: Men having Sex with Men, FSM Chuukese Population and Prenatal Women

•

• • •

- 46Annex 3 INDONESIA

STi-mV/AIDS TRANSMISSION PREVENTION PROGRAMME WITH COMDOM USE I.

Background

Today, Indonesia is facing many community health problems, one of them is HIV/AIDS epidemic where Indonesia is known as a country with concentrated epidemic, it means HIV/AIDS prevalence has been very high in certain places and sub-population groups. The HIVI AIDS epidemic is becoming a concern for all countries in the world. 100% condom use programme implementation has proven to be effective, and need to be developed in hIgh risk concentrated area. What is essential is provincial regulation to support the prevention programme. In Indonesia, according to Department of Health data until June 2006, there were 6332 AIDS cases and 4527 HIV cases reported in 32 out of 33 provinces. But, in 2002 the estimation for PLHA (People Living with HIVI AIDS) in Indonesia were around 90 000 - 130 000 people. Transmission of HIV is related to risk behavior. Therefore, prevention should be linked to the particular behavior. A clear policy in HIV prevention is included as part of the National Strategy on AIDS 2003-2007 - "Effective prevention including the 100% condom use among sex workers and client, PLHA and partner and utilizing of condom in the family - dual purpose for both disease prevention and family planning". Department of Health Republic of Indonesia estimated that around 7 - 10 million Indonesian men bought sex from sex workers each year. Results from Behavioral Surveillance Survey (BSS) 2003 ." conducted' by Statistical Center Bureau (CBO) indicated that knowledge of sex workers on "condom can prevent HIV transmission" were around 67%. But, from the same source only 13% men (on average) always use condom if having sex with sex worker. From the above data, we could conclude that if without any intervention, STD-HIVI AIDS will continue to increase.

II.

Type of Sex Work

Sex worker in Indonesia could be establishment based such as working at brothels, massage parlour, bar, discotheque, hotel/motel and freelance such as working at railway station, near the street, park, hut etc. Based on Village Potential Survey 2004 conducted by CBO, almost all city and district in Indonesia have sex workers (see map 1). According to National AIDS Commission (KPA) 2004, estimation of sex workers in Indonesia was about 1.2 million people.

III. 1.

Condom Promotion in Sex Work Strategy used and current status

1.1.

Strategy used

Main strategy for success of STD-HIV/AIDS prevention and transmission programme with condom use is existing agreement among owners and managers from all brothels to include condom use as one regulation of sex services. Programme components include: 1. 2. 3. 4. 5. 6. 7. Advocating Government commitment, executive and legislative, NGOs, LPS owner and Sex workers Institution Capacity building Availability and accessibility of condoms Funding Monitoring and Evaluation

- 47 -

Annex 3 2. Coverage

Target of STD-HNI AIDS prevention and transmission programme with condom use include the community, sex workers and client. Commumty strategy includes information dissemination involving formal leader and local government. For sex worker and client, information is given in specific places such brothels, bar, massage parlour, karaoke, night club and discotheque. Extension and expansion of programmes for sex workers must relate to the types of sex work and the locations where they are working. 3. Achievement and Impact of Condom Use Programme

Department of Health Republic of Indonesia has published a paper on 100% condom use to prevent sexual transaction. But, there are still many obstacles in the implementation and many sex workers are still not protected. Although knowledge about HNIAIDS and importance of condom use are high among sex workers and clients, the indicator on condom use is still low. Classic reasons given were reduce sex sensation, difficult to get condom, ashamed to buy condom etc. 4. Key Lessons learnt

It is still difficult to implement the 100% Condom Use Programme (100% CUP) in Indonesia. To improve the programme, all sectors need to work together - from government, manager of commercial sex, sex worker, client, community, NGOs etc.

5.

Future Plan towards Nationwide Scale-up

Although Indonesia has already made great efforts to control HNI AIDS, the result is still far from satisfactory. In 2003, National AIDS Commission has published National HNIAIDS Strategy 2003 2007 and made the amendment of the 1994 National HNIAIDS strategy. One of the most important justifications for amending the National Strategy is development of strategies to control HN I AIDS. The transmission and spread of HN is closely linked to risky behavior. For that reason prevention must take into consideration the factors that influence such behavior. One of the efforts IS effective prevention include 100% condom use for sex workers, clients and partner of PLHA, and 'double protection" condom use in families.

Mapl Almost aU City or District in Indonesia Reported the Location Sex Transaction

VUlage Potency Survey. CBO - 2004

- 48 Annex 3

LAO PEOPLE'S DEMOCRATIC REPUBLIC

1. Location

•

Borders Total land area Area Division Population Population growth Rural Population Urban Population Total Fertility rate GDP per capita Population below poverty line Adult literacy rate Net enrolment rate in primary education Ratio of girls to boys in primary education Female life expectancy at birth (years) Male life expectancy at birth (years) Modern contraceptive prevalence rate

• • • • • •

• •

•

Heart oflndochina Peninsular, South-East Asia, Land linked country Thailand (west), Myanmar (northwest), China (north), Cambodia (south), Viet Nam (east) 236800 square kilometers Provinces (16); Vientiane Capital; Districts (142); Villages (13 234) 5.6 million (2005), almost half ethnic groups (2005) 2.0% (2005) 7.8% 12.2% (2005) 4.9% (2000) USD450 (2005) 39% 75.4%% 81.8% 1:1.17 61

• • •

(1997) (2004) (2004) (2004)

•

(2000) (2000) (2000)

• •

57 29%

Lao PDR is classified as a low HIV-prevalence country with an infection rate of 0.08%. However, rapid changes are taking place, such as an upsurge of development in areas like infrastructure development, tourism and trade and service industries. There has been an increase in internal and cross-border migration since the country has opened its doors to the outside. UNSOL VED CHALLENGES INCLUDE:

2. 3. 4. 5. 6. 7. 8. 9.

HIV seroprevalence among sex workers has increased from less than 1% in 2001 to 2% nationwide (3-4% in some provinces) in 2004 STI rate among sex workers and their clients remains high The number of sex workers and their clients is increasing Partly low levels of knowledge on HIV/AIDS/STI among sex workers High mobility and turn over of sex workers Low preference of condom use among sex workers and their clients even though the rate of consistent condom use has increased from 2001 Alcohol plays a significant, and drugs a growing role in interactions between sex workers and their clients, increasing unsafe sex practices Low coverage of comprehensive response

- 49-

Annex 3

Types of Sex Work Definition of Sex Workers I service women Service Women (SW) takes diverse forms in Lao PDR. SWs are usually working in nightclubs, beer bars, drink shops, guest houses, motels and hotels as well as other casual settings (i.e. parlor shop) where clients can be found. There are also those freelance SW, those in the street and from phone network. Although SW are usually located in urban and big populated areas, it is also possible to find low priced SW working in casual settings in the rural areas ..

Estimated number of Sex Workers/Service Women:(6,681) This number is basically establishment-based such beer shops, karaoke, restaurants, night clubs, and guest houses. There is no data available such as the freelance SW, those in the streets and from phone network.

Provinces Vientiane Capital Phongsaly Luang Namtha Oudornxay Bokeo Luang Prabang Houaphanh Xayabouly Xiengkhouang Total

No.ofSW 1,588 141 198 195 130 118 190 278 180 3,018

Provinces Vientinae Province Borikhamsay . Khamouane Savanakhet Salavan Xekong Champasack Attapue Xaysomboun Total

,

No.ofSW 1,280 92 450 600 191 104 714 185 47 3,663

Condom Promotion in Sex Work Strategies and Current Status: The overall strategy targeting the female sex workers and their clients where condom is a cross-cutting issue includes: • • • • Create a supportive environment for behaviour change among SWs and their clients. Ensure that SWs and their clients have correct knowledge on HIV and STIs and have the motivation, power and means to act on their knowledge. Ensure sensitive quality services for sex workers and their clients. Improve knowledge about behaviour, practice and networks of sex workers and their clients in order to monitor effectiveness of existing interventions and to guide development/modification of potential interventions.

Coverage (target group, geographical and services) As part of the National AIDS Control and Prevention Programme, condom distribution and coverage is part of the national strategy to make condoms widely accessible and available. The activities include provision of condoms, through STI services, outreach activities, and peer education, being promoted by Centre for HIV/AID SISTI (CHAS) together with its partners.

- 50 -

Annex 3

PSI's Social Marketing mainly targets sex workers and their clients. Condoms are available in around 98.2% pharmacies nationwide and 100% in non-traditional outlets such as hotels, guest houses, night clubs and beer houses in 3 provinces with 100% CUP namely, Savannakhet, Khamouane and Oudornxay Achievement and Impact

Percentage of condom use & STD infections in VT Capital & Savannakhet Province ~

83 00

70

_

HIV information past 6 months

..• "-

&I

~

50 40 30

r:::::::J Consistent condom use with

dients pilSt month

-.-Gonorrhea or chlamydia

infection 20

10 0

As a result, the rate of condom use in sex workers rose from 16.2% in early 2000 to greater than 83.16% in 2004, and the annual incidence of sexually transmitted infections was declined, from almost 43% before the programme to less than 30% in 2004. Key Lessons Learned

The following were the lessons learned from the 100% CUP in three provmces: • • • • Creating an enabling and supporting environment with commitments and support from central and provincial government and authorities facilitated the programme. Involvement of entertainment establishment's owners in managing the programme that does not threaten their interests. The IEC activity to make condom use and STI treatment acceptable 15 effective. Making condom widely available, accessible and affordable is very important.

- 51 -

Annex 3

•

• •

Structure support to guide, control, monitor and manage the programme was well orgarnzed. These include the 100% Condom Use Monitoring and Evaluation Committee, Condom Use Working Group and related working teams. 100% CUP plans should be more comprehensive with clear indicators for better monitoring, supervision and evaluation of the programme's outputs and impacts .. Condoms availability in non-traditional outlets is possible only with the government support to facilitate 100% CUP.

Future Plans Towards National Scale-up

Based on the National Strategic and Action Plan on HN/AIDS/STI 2006-2010, condom promotion will be one of its major interventions together with Behavior Change Interventions, STr Services, VCT, Enabling environment, Awareness Campaigns. The Plan aims to reach full coverage of targeted and comprehensive interventions in prioritized provinces/districts in a phased approach. Future plans for condom intervention include: • To make the condoms widely accessible, available and affordable, it will be distributed through outreach, drop-in centers (DIC), social marketing including non-traditional outlets (mamasans, bars, beer-lao, etc.), and 100% condom use promotion (CUP) programmes. The scaling-up of 100% CUP: by 2010 Lao PDR will have scaled up 100% CUP at the natIOnal level and all provinces will have implemented the programme. The expected outcome by 2010 is the consistent condom use in 80% of sexual interactions between female sex workers and their clients.

• •

PSI/Laos will scale up condom social marketing through non-traditional outlets in others provinces with Global Fund HIV and AIDS funding.

- 52 Annex 3 MONGOLIA Country

Mongolia is a landlocked country located in North-East Asia with the population of 2.5 million people. One-third of the population lives in the capital city Ulaanbaatar. CURRENT HNIAIDS/STI SITUATION In 1990, Mongolia embraced democracy with an open market economy. This dramatic transition resulted in enormous social and economic changes like increasing poverty, unemployment, increased in internal migration, alcohol and high-risk behaviour. Neighbouring Russia and China are the countries with rapidly growing and spreading HIV epidemics. STIs are the first leading group of communicable diseases reported in the country comprising 47.4% of aJl reported infectious disease cases in 2005. The prevalence of STI among the general population remains high, and is highest among the high-risk groups. Accordmg to the second generation sentinel surveillance survey results of 2005, the highest prevalence of syphilis was among MSM (22%) and SWs (17.4%). Mongolia is categorized as a low HN -prevalence country. Although the official prevalence rate is less than 1% among the general population, the number of reported cases is exponentially increasing. As of September 2006, a total of 25 cases of HN infection are reported. The true nature of the epidemic is unknown due to insufficient testing. UNAIDS/WHO estimates that there is likely to be 500 actual cases ofHN infection in Mongolia. Types of Sex Work

The influx of young women and men into the trade is mainly a result of poverty, greater mobility, increasing consumerism and increasing social and sexual liberty of young people. Sex work IS very common in the capital city and urbanized communities. The number of SWs (estimated number of commercial SWs is more than 4000 in Ulaanbaatar city) is constantly increasing in the capital and other large cities, and border areas with more younger entrants into the sex business. Most of the SW s in Mongolia are freelancers and are not affiliated with any entertainment establishments. Bars, karaoke, night clubs are mainly used by SWs as potential places for picking up clients, and the sexual activity is conducted mostly in nearby hotels. However, in the last two years sex work in saunas and massage parlors has become popular. Most of these establishments now serve as brothels with their own SWs. Street SWs can be found near the railway stations and market places, with clients who are mainly traders, truck drivers and businessmen traveJling to Russia, China and within Mongolia. Many SWs work in China and other countries. In addition, many young women are being trafficked to the countries of Asia and the Pacific. Condom Promotion in Sex Work

STRATEGIES USED AND CURRENT STATUS UNFPA, the Global Fund supported HNIAIDS project and Marie Stopes International CSM project have been supplying condoms using the estimation of the MoH and UNFP A on condom needs for the years 1999-2010. Limited number of condoms is available for free at family planning and STI clinics throughout the country. Condoms are also distributed for a reduced price through social marketing since 1998. Private sector is importing condoms but the quantity is still small. The SWs are being supplied with free condoms as incentlves for their involvement and compliance with the 100% CUP. Other role players in the 100% CUP (hotels, bars, night clubs and other entertainment establishments) are being assisted in establishment of a co-operation with the MSI condom social marketing project. The free distribution of condoms is planned to be gradually replaced by condom revolving funds at local and institutional levels. The social marketing approach is still being promoted by the key role players in the HN/AIDS prevention and control efforts in Mongolia.

- 53 Annex 3

The representatives of law enforcement agencies used to believe that their participation in the programme conflicted with the current Penal Law on Prostitution and Pornography. It took time and effort to convince the police to become an important part of the programme. The attitude of police officers towards SWs has changed and they give more importance to the participation of SWs in the programme, and the prevention of the involvement of SWs in crimes. SWs' NGOs in Ulaanbaatar and Darkhan have been actively participating in the 100% CUP implementation programme and involving SWs in the programme through outreach workers and peer educators, facilitating regular check-ups and testing of SWs, conducting regularly IEC and behaviour change activities, actively collaborating with other partners, and sharing information and experience. Agreement established with hotel owners include activities that help to ensure condom use by SWs and their clients. These include availability and accessibility of condoms and establishment of IEC comers. These have also been included in hotel service standards that have been strictly adhered in the province. Health organizations have provided technical and professional assistance, conducted relevant training courses, seminars, meetings and discussions, have provided support in training of SWs as peer educators and outreach workers, have provided free monthly check-ups, testing and treatment for STIs, encouraged participation of SWs, have provided monitoring of correct and regular use of condoms, monitoring and evaluation of the programme implementation, and reporting to the local Programme Coordinating Committee. COVERAGE

Target population: freelance SWs located in Ulaanbaatar city (9 districts) and 11 provinces. Activities included capacity building of local staff, meetings of provincial authorities, meetings of hotel owners and entertainment establishments, outreach and the use of peer educators among SWs. Services provided: Voluntary counselling and testing, free treatment, peer education training, outreach and IEC activities, condom distribution. Monitoring of condom use has performed by monthly checkup for STIs, survey among male STI clients regarding their contacts with SWs, "mystery clients" and monitoring of condom sale and distribution. ACHIEVEMENT AND IMPACT

The Ministry of Health with WHO financial and technical support started a pilot project on 100% CUP in Darkhan-Uul province in 2002. As a result of implementation of the 100% CUP in Darkhan-Uul aimag, condom use among SWs increased 7.2 times from 13% to 93% and STI decreased from 72.8% to 3%. Reported STI and condom use rate among SWs in Darkhan-Uul airnag (2001-2005)

- 54Annex 3 STr prevalence in the general population in Darkhan-Uul province has declined from 17 per 10 000 population in 2002 to 11.1 per 10 000 population in 2005. Condom usage among general popUlation increased 13 times compared to 2002. No HIV infection detected during project implementation.

STI rates in Darkhan-Uul aimag per 10000 popu lation (1999-2005) 20 15 10

lEI STI prevalence 1999 2000 2001 2002 2003 2004 2005

i

5

o

In Darkhan-Uul aimag, SWs were twice more likely to use a condom at the last sex with nonpaying, non-regular partner (OR=2.5; 95% CI 1.3 to 4.7) and 10 times more likely to use a condom at the last sex with regular partner (OR=I 0.4; 95% CI 2.9 to 36.6) compared to Ulaanbaatar city SWs. In other provinces implementing 100% CUP over a period of a year, condom use with clients among SWs was also high (90.2%).

Police harassment has reduced as a result of changes in attitudes of police officers. Crime prevention activities among SWs have already paid off by decreased number of violations of laws and regulations by SW s - no SWs has been charged with any kind of crime since 2002. There was a strong political commitment from the province, particularly the Provincial Governor, the Police, health sector, hotel business and entertainment sector as well as an NGO working with SWs. Participation of hotel owners and entertainment sector is quite strong, as they are proposing some representatives to be members of the 100% CUP Coordination Committee, chaired by Deputy Governor of the Province. In addition, SWs who form themselves as a self-help group, has provided peer educatIOn training to work together to refuse condom-free sex, to educate and disseminate condoms to other SWs in the city. LESSONS LEARNED:

• •

Collaboration of the police in the enforcement of the use of "green cards" has been proven to be very effective in involving SWs in the programme. Most of the SWs in Mongolia are freelancers and are not affiliated with any entertainment establishments. This is different from the sex work situation in most other countries of the Region. Collaboration with NGOs to reach freelance SWs is found to be effective. The health sector alone could not have succeeded in achieving current results. The success of the pilot programme is due to a coordinated collaboration of provincial authorities, professional control agencies, police, private sector, NGOs and health sector. It is important to conduct effective advocacy and behaviour change interventions among

•

•

implementing organizations and individuals in order to improve their knowledge and change attitudes towards prevention ofHIV/AIDS/STI among SWs and their clients. • There is a need to conduct IEC activities with design and contents that match the needs of specific target groups (decision makers, police officer, entertainment establishments owners, SWs, health personnel, pharmacists. etc).

- 55 Annex 3 • Producing and distributing a sufficient quantity of IEC materials to hotels, bars, and other types of entertainment establishments may be an effective way of providing HIV /AIDS/STI prevention information to high risk groups. It is advisable to establish condom revolving fund using condoms that are granted by UN agencies and the Global Fund in order to ensure the sustainability of high quality condom supply. In addition, the revolving funds may bring revenue that could be used for funding of prevention interventions in high-risk situations. Conducting regular training sessions and meetings with partner organizations have been useful given the high staff turnover in the public sector. It has been useful to have regular roundtable discussions, official consultations, experiencesharing meetings, seminars, workshops and brainstorming sessions involving all participating organizations. 100% CUP interventions should be carried out along with the activities aimed at clients of SWs, such as IEC activities aimed at the general population, general condom promotion, client friendly STI services, contact tracing, etc. This should be considered during the expansion phase of the programme.

•

• •

•

FUTURE PLAN TOWARDS NATION-WIDE SCALE-UP

The National Public Health Committee (NPHC) has reviewed the status and results of implementation of the 100% CUP in Darkhan-Uul province, and has made a decision to expand the programme to other provinces and the capital CIty of Mongolia. In May of 2005, the NPHC issued an Official Statement of Obligation number 01 of 2005 endorsing the nationwide expansion of the 100% CUP: "expand the implementation of the 100% CUP at the national level starting the second quarter of 2005 with active collaboration with the international organizations and nongovernmental organizations". Now, the 100% CUP has been expanded to other 10 aimags and Ulaanbaatar city. With funding support from Global Fund Project Round 2 (2003-2008) and Round 5 (2006-2011), it is expected that nationwide implementation will be accomplished by 2008.

- 56 -

Annex 3

PAPUA NEW GUINEA Country Information

Papua New Guinea (PNG) is one of the world's most diverse countries-geographically, biologically, linguistically and culturally. It is located just north of Australia and is made up of the eastern portion of the island of New Guinea (the Indonesian province of Irian Jaya covers the western half of the island) as well as a series of Islands to the north and east of the main island - Manus, New Ireland, New Britain, and Bougainville, the central part of the main island, known as Highlands rises into a wide ridge of mountains up to 4500 metres high. Geographically, the country has high mountain peaks, hills, grasslands, long and winding rivers, lots of open seas. PNG has a population of approximately 5.3 million people, 52% of whom are women and girls. The population has grown rapidly since 1975 at an average annual rate of 2.5%. Half of the population is under 19 years of age, and over 85% live in relatively isolated areas with limited or sometimes no access to basic services. The average life expectancy IS 54 years and adult literacy is estimated to be 52%. PNG has more than 800 languages, over 1000 dialects, has many tribes, sub-tribes, clans, sub-clans and family groupings. Ninety nine percent of Papua New Guineans identify themselves as Christians and the churches playa very strong role in PNG society, including in the delivery of social services. English is now the main medium of government communication (especially at the national level and for educational instruction), there are three official languages-Pidgin, Motu and English. Majority of PNG's population (about 85%) live in rural areas and rely on subsistence or small-scale cash crop agriculture for their livelihoods. However, PNG also relies substantially on the export of non-renewable resources (copper, gold, silver, natural gas) as well as timber, coffee, copra, palm oil, cocoa, tea, coconuts and vanilla for foreign exchange and government revenue. Mining alone accounts for 72% ofPNG's export earnings and 24% of the GNP. PNG has experienced annual GDP growth of approximately 3% since 1975. However, the economy suffered a setback during the fmancial crisis of the late 1990s and has expenenced a significant decline since then. GDP per capita has actually fallen consistently since the mid1980s reaching US$ 1,150 in 1999, then falling to US$ 825 in 2002. While its abundant resources provide PNG with great potential for economic diversification, growth and self-reliance, it has not resulted in economic well-being for the majority of the people. In fact most social indicators remain low and the level of poverty has increased faster than in neighboring countries m recent years. According to UNDP Human Development Index, PNG ranks 133 out of 175 countries. Types of Sex Work

Sex workers (SWs) are of particular interest due to their lifestyles, the nature of their work and the fact that they have a high partner exchange rate. The number of sexual partners for self-defined full-time urban sex workers per year has been reported to be as high as 300 to 900, more in the order of 500 to 2000 in the past whilst the highest number of customers per sex worker in a week recorded is as high as thirty. SWs therefore represent a core group of heterosexual transmission and have been associated with the spread of sexually transmitted infections (STls); the major co-factors in transmitting HIV. Their lifestyles have caused societies societies to relegate them to the margins. The social and moral stigma allotted SWs have become a major barrier resulting in poor health seeking behaviors and poor access to health promotion and prevention services, especially condom use. The health effects and the

- 57 Annex 3 associated socioeconomic issues are a significant public health concern for the Papua NeVi Guinean society. Sex work is now common in both towns and rural areas around the country. Unlike other countries, sex work in PNG is not usually organized into brothels. It is predominantly street based or free-lance around bars and discos. Tentatively, there is an estimated 10 000-12 000 freelance sex workers who operate from the streets, the 'bushes' and other informal settings. These hot spots are places where sex is rife but it is not in an organized manner like a brothel. Although sex work is illegal (and usually when the police are involved consequences are stiff), there are "Papas, mamas and Pamuk houses" in PNG especially in towns, and rural enclaves where gold mines are now operational. The presence of "Gatekeeper', 'Buskrus" and "Wasman" in some organized underground sex hot spots means there is some form of sex work which may resemble brothels. STIs in PNG are estimated to be among the highest in the Asia Pacific Region. A high prevalence of STIs in any given population significantly increases the risk of HN transmission and it also indicates a high degree of unprotected sex. STIs are a matter of urgency because HNIAIDS transmission through STIs is becoming more prevalent in PNG. Strategies

Several strategies have been employed successfully to decrease STI rates in SW communities. These include the promotion of condoms, STI case management and presumptive treatment. The presumptive (epidemiologic or selective "mass") treatment of STI is an alternate approach that has been shown to decrease STI prevalence markedly among at risk populations. The use of mass media, posters, brochures, peer education and one to one education has also been applied. STRATEGIES FOR SOCIAL MARKETING OF CONDOM

• • • •

• •

Establish commercial and community channels for condom distribution, targeting trade stores, supermarkets, hotels and disco places, and community sport groups. Provide training on STIIHNIAIDS for distributors. Link condom distribution to peer education, parent and community awareness programmes, and reinforce and strengthen links with family planning clinics. Ensure condom packaging is attractive and informative, includes written and visual instructions for correct use and disposal, the expiry date, suggested use with water-based lubricant, and positive health messages. Set affordable and controlled price for condoms with the possibility of price incentives. Ensure condoms distributed are of good quality, are properly stored, and do not exceed their expiry date.

CONDOM USE

Reported condom use varied by SWs and consistent condom use was low, between 30-40% amongst both SWs and their male clients. These fmding are consistent with finding from other previous studies. The liN prevalence amongst SWs in Port Moresby has been reported at 17% and consistent with data presented in this report (19.4%). A behavioural surveillance among 480 antenatal women (low risk) at Lae in 2003 found 75% never used condom during sexual intercourse with their husbands and the remaining 25% sometimes. The condom use was less than 30% in the low risk group similar to the pregnant women in PNG before 2005. Studies done on condom use and distribution among SWs and general population have always been low. The influence of the religious groups as well as some government stance in some

- 58 -

Annex 3 provinces on condom use and distribution in PNG has decreased its use by those who may need them. In a study done by World Vision International in 2004, there was an improvement of condom use when it was taken to where the sex work was being conducted. From this study it was also worth noting that condom use improved when SWs' clients were involved. It was also noted that Male condoms were more popular than the Female condoms. The numbers collected ranged from between 1,000-1,300 in the beginning of the study, peaked at approximately 1400 and reduced to 200-300 in 9 months after the study. In a study conducted by World Vision International and another presented at the 2006 PNG Medical Symposium in Madang, showed that high rates of condom use observed in these studies should greatly have reduced STI infections but the opposite was observed. These reported condom use may be over-estimated in which case the target population were taking treatment but getting reinfected, and possibly the condoms were being used for other purposes such as fishing. It was also reported that the lubricant in the condoms was good for curing skin conditions. The Government of PNG has a 100% condom use policy implemented through the National AIDS Council and National Department of Health. It empowers SWs and sexually active persons to use condom every time they have sex. In the marriage, the interpretation of the policy may differ. There are generic condoms and the NAC branded Karamap (condom) that are available for use in PNG. The effectiveness of this policy is yet to be nationally evaluated by a neutral research organization. Although PNG general population has heard of condoms, the coverage has not been so successful. In some areas target groups such as the young and SWs do not have access to condoms and other services such as care and treatment for common STIs. PNG, being 85% rural, makes it even more difficult to discuss and negotiate for condom use. Religious influence is common in these areas and so use and discussion of condoms is a taboo. KEY LESSONS AND FUTURE PLANS

The studies done over years provide information of potential relevance to other settings where sex work is common and can be used as strategy for STI interventions. Correct information to target populations and the general public should be consistent and in a language understood by the people. Involvement of Church leaders, politicians and other community leaders is cardinal, as PNG is still influenced by the community and church leaders. More shelters for women, SWs and youth friendly centres should be countrywide to avoid stigma and let people seek help early. In public STI clinics where female patients were seen by female healthcare providers the distribution of condoms was high. Periodic treatment every three months for the 10 month study period proved to have significant impact on STI prevalence among SWs and condom accessibility by SWs and clients should be encouraged. GLOSSARY OF TERMS

Buskrus Wasman Mamas Papas Pamuk PamukHouse

A guard for sex worker A person who watches over the sex worker during a sex act to ensure that she is not exploited by a client. A pimp- like female guard for sex workers. Also acts as a mother figure for sex workers. A guard for sex worker who assumes a father-like role A generic term for sex worker or one with multiple sexual partners A house where sex work takes place

- 59 Annex 3 Head girls Gatekeepers "Wet lunch" "Afiernoon Jump"

Sex worker point person or a leader A person outside a target population who has both influence and control over access to that audience A tenn used by sex workers to indicate sexual activities during lunch breaks accompanied by a plate of lunch. Sex during the day time especially in the afternoons

Disco meri These women are usually paid more in cash, food and drinks, earn between K20 and K50 per customer and may have fewer partners. They mostly work indoors, during the night and around the clock (night and day) from offices, men's own homes discos, hotels, small guest houses bars and in cars. They demand set prices for various sex acts unless they are desperate for money. They are generally better paid than the 'two kina meri·. The peak times for customers are at lunch times, late afternoons, holidays and paydays and customers pay for the rented rooms. Periodic presumptive treatment (PPT) Also known as mass treatment: STI treatment of individuals presumed to be infected with one or more STIs, without attempting to make an individual diagnosis. PPT can be targeted to persons with known high-risk behaviours for example, sex workers. It is done by administering I gm Azithromycine as PPT to a core group of people at certain intervals, with the presumption that many are infected with STIs. Alternatively, mass treatment can be provided to the general population, without attempting to target those who may be at increased risk. Policy of 100 percent condom use in sex work An intervention that seeks to reduce transmission of HIV and other STIs to and by sex workers by ensuring that condoms are used for every act of intercourse. Plural Partners These are males or females who have multiple sexual partners but are not termed as sex workers as they are not paid nor get goods in exchange, but may get services in form of protection from violence, housing etc.(from Mamas and Papas). Sex Worker Female, male and transgender adults and young people who receive money or goods in exchange for sexual services, either regularly or occasionally, and who mayor may not consciously define those activities as income-generating" (UNAIDS, June 2002). Sex Worker Client An individual who exchanges (buys or pays) money, gifts or goods and services for sexual activity Tu Kina bus meri This comprise of the least paid (K2 - K20 per sex act (PNG K=US$ 0.25) and by far the most numerous. They mainly work outdoors such as the on the roads and streets. They are also popularly known to have sex in weedy and bushes areas, hence the name "Tu Kina bus meri" (a female who has sex in the bushes for payment of two Kina). These women mostly work during the daytime and have approximately 300 to 900 partners per year. Their customers are usually men oflow income earners.

- 60 -

Annex 3 PIDUPPINES Country Profile The Philippines is an archipelago in Southeast Asia composed of 7,100 + islands with a population of 86,241,697 (July 2004 estimate) and a population growth rate of 1.88%. 35.8% (30,874,527) are children aged 0 - 14 y/o. Literacy rate is 92.6%. Background of National AIDS STI Prevention and Control Program (NASPCP) The STD Control Program in the Philippines started in 1945 in response to the increasing incidence of STD among US military men and Filipino civilians. This led to the establishment of the first Social Hygiene Clinic (SHC) in Manila. The STD Program was under the Bureau of Disease Control during those years. With the first AIDS case in the Philippines was recorded in 1984, a special program for HIV I AIDS Prevention was created. It was placed under the Communicable Disease Control Service (CDeS) of the Office of Public Health Service of the Department of Health. The STD Control program was integrated with the National AIDS Prevention and Control Program in September 1993 and which is currently known as the National AIDS/STD Prevention and Control Program (NASPCP). PROGRAMME GOAL AND OBJECTIVES

Goal

Prevent morbidity and mortality from HIV /AIDS and other reproductive tract infections.

Objectives ~ ~

~

Decrease the incidence of STI by 50% among the more vulnerable groups. Increase the rate of condom use by 40% among the more vulnerable population. Contain the prevalence rate of HIV/AIDS the general popUlation to less than I and among high risk / more vulnerable population to less than 3%.

Programme Strategies ~ ~

~

~ ~

~

~

Extend disease surveillance and diagnostic facilities to other sites to increase coverage and improve case detection. Prevent mother-to-child transmission of HIV/AIDS. Prevent and control HIV/AIDS and STI transmission among sectors dealing with human body, human parts and tissues and human fluids such as allied medical and paramedical health personnel, embalmers, mortuary workers, tattoo artists though capability building both in public and private facilities Promote safe sex and other positive behavior relevant to the control of HIV -AIDS and reproductive tract infections among the vulnerable and general population. Address stigma and discrimination against the vulnerable groups by the general population by promoting local government-initiated and community-based programmes. Strengthen collaboration of the Department of Health with Local Government Units (LGUs) and nongovernmental organizations (NGOs) to reach out and provide acceptable, accessible and affordable medical and social services to the "hidden" vulnerable/marginalized groups. Research and development for the advancement in the management ofHIV/AIDS and other reproductive tract infections.

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- 61 -

Annex 3 ~

Improve the central management of the multi-agency, multi-sector programmes through a regular review of roles and responsibilities and by installing a comprehensive monitoring and evaluation system.

100% Condom Use Programme In 2002, the World Health Organization funded a pilot project for 100% Condom Use Programme in the cities ofUrdaneta, Dagupan, Laoag and San Fernando, La Union.

STRATEGIES USED The implementation of this project was done in four sequential stages: (1) Advocacy / orientation - this is done with the Local Government Executives (LGEs) and other stakeholders by means of a one day workshop. The champion for the 100% CUP is identified and acceptability for the programme is established.

(2) Capacity building/training - this ensures that before the implementation of the programme, stakeholders are provided with adequate capability to operate the 100% CUP. (3) Operation - programme strategies and activities are put in operation. As part of the learning process, participants from the different LGUs are brought to a study tour in areas where 100% CUP has been institutionalized and already considered a success. Process monitoring is conducted during the implementation period to ensure that strategies are correctly carried out. (4) Monitoring and evaluation - this takes place after about a year the programme becomes fully operational. A consultative meeting /updating is done to determine difficulties and possible solutions for these. The activity is periodically conducted until such time the strategy is fully institutionalized. CURRENT STATUS The four pilot cities for the 100% Condom Use Programme serves as models for the nationwide expansion plans. COVERAGE (TARGET GROUP, GEOGRAPHICAL AND SERVICES)

The target groups are: (1) Registered Sex Workers (RSW) are sex workers who are registered in the Social Hygiene Clinic/ Reproductive Health Centre or health facility and are given a health card and work in registered/licensed establishments. They may be regular or contractual (dancers and models). Establishments may include bars, casa, massage parlors, nightclubs, beer houses, karaoke bars or cafes. Freelance sex workers (FLSW) are sex workers who exchange sex or favors for money and who mayor may not be working in an establishment, and are not registered with the Social Hygiene Clinic/ Reproductive Health Centre or health care centre. Men who have sex with men (MSM) are men who have sex with other men for their own pleasure. These may be men who negotiate sex with male commercial sex workers. MSM are usually accessed in cruising areas, theaters, gay bars, beauty parlors, dress shops or gay organizations. They may be self identifying homosexual men or bisexual and covert homosexual men.

(2)

(3)

- 62Annex 3 (4) Identifiable groups of clients of sex workers are men who pay female sex workers for sexual services that may include penetrative acts such as vaginal or anal intercourse and oral intercourse. Other vulnerable groups. Youth are men and women ages 15-24.

(5)

GEOGRAPHICAL AND SERVICES

(1)

Provide access to effective and acceptable STI services to vulnerable groups Improve STI services of Social Hygiene Clinic! Reproductive Health Centre:

•

• • •

• (2)

Simple Modification of the Clinic setting with provision of waiting room and ample examination rooms. Improve clinic based communication through provision of standardized set of behavior change related messages for clinicians to use. Training on STI Comprehensive case Management for STI Service providers. Expand the reach of SHC/ RHC services to include freelance sex workers, other risk group and the youth. Strengthen relevant laboratory support to STI services with the provision of effective STI diagnosis and screening for asymptomatic STI cases in women.

Promote appropriate STI health care seeking behavior through education of STI clientele.

(3) (4) (5)

Establishment of STI Surveillance through the STI Sentinel Etiologic Surveillance System. Advocate to LGUs for continued support to ensure sustainability of the programme. Develop a system of monitoring and evaluation:

ACHIEVEMENT AND IMPACT

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- 63 -

Annex 3 KEY LESSONS LEARNT

• • • •

Ownership and commitment ofthe local government officials are enabling factors Community involvement is an "enormous" factor in identifying the needs and problems of the four pilot sites A multi-sectoral approach is a unifying force for the success of the local programme Organized entertainment establishment owners and entertainers (peer educators, GROs, etc) are empowered

FUTURE PLAN TOWARDS NA TlONWIDE SCALE-UP

The "100% Condom Use Programme (100% CUP)" was implemented in the Philippines in collaboration with the World Health Organization. The multi-sectoral collaborative effort is quite effective in the control and prevention of STI which accounts for more than 80% of HIV is transmission. The DOH has joined efforts with the Phihppine National AIDS Council (PNAC) in expanding the 100% CUP to strategic areas in the Philippines as mandated by RA 8504 and expressed in the 4th Medium Term Plan for the Prevention and Control of HIV/AIDS. The following areas had been selected for expansion in 2006: 1. Region 10, four cities 2. Region 9, one city 3. Region 6, five cities 4. GFATM sites, 11 cities

- 64Annex 3

SRI LANKA Country Information

Sri Lanka Province Map N

Qul'o!

Mann.,

BAY OF BENGAL

f

Indian Ocean

I ~; ICountry Capital ~ Proviooe Capital Copyright O'Comp6re-tl"lfob~-PVl Ltd, 2004.05

[!Jlmportanl Cities

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Population Total Sinhalese Tamil Muslim & Burger Other 20 million 74% 18% 07% 01% 09 24 Colombo 0.9%

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Provinces Districts Capital Population Growth Rate

- 65 -

Annex 3 HIV INFORMATION (TILL MARCH 2006) ~ ~ ~ ~

~ ~

~ ~ ~

Number of People living with HIV Classified as a low-level epidemic country HIV Prevalence rate among high-risk population Mother-to-Child Transmission Estimated HIV Population National Prevalence ofHIV Cumulative AIDS cases Male 152 Females 61 Reported deaths Male:Female Ratio Most of the Infections acquired by Heterosexual sex HIV sero-positivity rate 2005

771 <5%

24 3500-8300 <0.1% 213

147

1.4: 1 0.05%

Types of Sex Work In Sri Lanka, legally-based sex activity centers (brothels) are prohibited. ~ ~

~ ~ ~

;;. ~

;;. ~ ~

~

But unofficial brothels are found Massage parlors Karaoke centers Night clubs Hotels Freelance (along highways / railway stations / shanties) Vehicles / balconies / parks / "lovers lane" / film halls Beaches Prisoners / Migrants (local/foreign) Drug users (iv) Casual sex work • With Officemates • Teachers • Garment Factory Workers • For pleasure [when not satisfied with the partner1 Total estimated sex workers 30000

Condom Promotion in Sex Work STRA TEGIES USED FOR CONDOM PROMOTION ~

Free distribution to: Government health institutions, (e.g. PHlGHlBHlDHIPUIRU/CDs, MOH) Family Health Bureau IFamily Health Association Social MarketinglMass distribution (at subsided prices) Pharrnacies/SuperrnarketsNillage Shops Condom Programming Demand, Supply and Support services

~

~

- 66Annex 3 Demand includes Research Education Distribution Sales Supply services Forecasting and procurement Distribution systems CURRENT STATUS OF CONDOM PROMOTION

Distribution Quality management Logistical information systems Support services Policy Management Staff development

Total number of condoms imported

about 12 million

Various programmes are in progress at the level of PDIRDHSIMOHINGO with regard to advocacy, improving of knowledge, reducing stigma and discrimination, improving care procedures, training of TOT in hotels, prisons, workplaces, armed-forces, transport sector, MOH staff, administrators, etc. COVERAGE IN TARGET GROUPS

Schoolleavers Female sex workers STI patients at STD clinics Transport workers Hotel management Workers - Garments Estate Beach boys Massage clinic workers Night clubs Forces

before leaving school through health education, exhibitions when diagnosed STls attending clinics education, exhibitions health education, exhibitions

health

Workshops, health education, exhibitions

SERVICES RENDERED BY HEALTH DEPARTMENTINGOSIMEDIA ISLAND WIDE

e.g. Health department health education supply of condoms development of IEC material training of trainers research on condom programming caring of STI and HlV/ AIDS patients sustain co-operation ofNGOs and other organizations in preventive aspect

- 67 -

Almex 3

ACHIEVEMENTS

Several achievements gained from the RRI programmes in various provinces, e.g. 1. In some of the selected hotels in UV A province, the couples visiting their places were given IEC material and condoms free of charge. There, basic study was done and found that only 40% of the couples carried condoms with them. This was increased to 85% in RRI programme held for 100 days. 2. Increase female sex workers seeking sm clinic 20%-70% in 100 days and this was completed effectively. servIces from

3. Gradual increase in condom distribution was also noted in the previous year. KEy LESSONS LEARNT

l.If continuous monitoring could be done, the achievement of 100% condom use is feasible.

2. Several monitoring bodies must be utilized. 3. Sustainability could be done if adequate funds are provided. fuTURE PLANS TOWARDS NATIONWIDE SCALE UP

1.

100% use of condoms in sexual relations (where unauthorized sex activities are held)

2. Institutional strengthening 3. Regional, extra regional and local training for human resource development 4. Strengthening surveillance systems 5. Comprehensive management information system 6. Research 7. Information, Education and Communication (IEC) 8. 9. Involvement of other sectors on HNIAIDS Prevention. Involvement of Nongovernment Organizations

10. Political commitment 11. Involvement of provincial health authoritIes 12. Involvement of private sector

- 68 -

Annex 3

VIETNAM

Country ProfIle GENERAL INFORMATION

I I

:==:======:I Age structure: Median age:

!Population:

11184402 966 (July 2006 est.)

0-14 years: 27% (male 11 826457/female 10 983 069) 15-64 years: 67.1% (male 28 055 941/female 28 614 553) :::=====~ 65 years and over: 5.8% (male 1 924 562/female 2998384) (2006 est.) total: 25.9 years male: 24.8 years ~====~ Ifemale: 27.1 years (2006 est.) Population growth rate:

I .

11.02% (2006 est.)

:========:::::; lDeath rate: i 16.22 deaths/1 000 population (2006 est.) :=======:::::; Sex ratio: at birth: 1.07 male(s)/female

:========: !Birth rate: !!16.86 births/1 000 population (2006 est.) under 15 years: 1.08 male(s)/female 15-64 years: 0.98 male(s)/female 65 years and over: 0.64 male(s)/femaJe total population: 0.98 male(s)/female (2006 est.) Infant mortality rate:

total: 25.14 deaths/IOOO live births male: 25.54 deaths/IOOO live births female: 24.72 deaths/IOOO live births (2006 est.) total population: 70.85 years male: 68.05 years Ifemale: 73.85 years (2006 est.)

Life expectancy at birth:

:=========! !Total fertility rate: i 11.91 children born/woman (2006 est.) HIV/AIDS INFECTION (2002-2006) Up to 30 June 2006, HIV positive accumulation was reported 109 989 cases nationwide, of which there are 18581 AIDS cases and 10785 died of AIDS.

- 69 Annex 3

Table 1: Number ofHIVIAIDS infected casefoundji-om 2002 to date Number of HIV infected case per year

2002 15790 t42.32%

2003 16980 17.54%

2004 14200 .116.37%

2005 13 731 .13.3%

6/2006

5878

In comparison with previous years Number of AIDS cases t;

2249 1'38.31 %

2866 127.43%

2769 .13.38%

2861 1'3.32%

1292 714

Number of patients died by AIDS t;

1336 1'36.05

1661 124.33%

1848 tll.26%

1673 .19.47%

Analysis by age:

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20·29

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30·39

Analysis by sex

Analysis by high-risk groups

Unclear 0.22%

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Female 15.21%

5 L68%

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- 70HN INFECTIONS IN HIGH-RISK GROUPS

Groups IDUs SWs Antenatal women TB patients STI patients Military candidates in medical examination TYPES OF SEX WORK

2002 29.35 5.90 0.34 3.62 , 2.13 0.65

2003 27.70 3.76 0.24 3.28 1.37 0.41

2004 28.61 4.42 0.35 4.45 1.35 0.47

2005 25.45 3.53 0.37 4.21 2.52 0.31

I I

I

There are two main types of sex work in Vietnam at this time: entertaiment establishment based and street based. However, there are no official statistics about these.

Condom Promotion in Sex Work STRATEGIES USED AND CURRENT STATUS • In 1999, the Ministry of Health (MoH) of Viet Nam inspired by some successful regional experience, and with the support of WHO, started piloting the 100% condom use programme (100% CUP). Within a few years ten 100% CUP pilot projects have been implemented. Provincial Heath departments are fully responsible for programme implementation that should be as multi sectoral as possible. Activities include community work with SWs on condom promotion, regular detection of STls and social marketing of condoms. The approach was always reviewed and refined based on the local experience of the implementers at provincial level. In parallel to the implementation, the 100% CUP model was extensively promoted at central level among all stakeholders at the Ministry of Health and outside in order to gain more support for the implementation

• •

From 2001 - now: there has been some condom social marketing strategies, conducted by many NGOs and INGOs However, until recently preventive activities among SWs, especially condom intervention was a sensitive issue which makes interventions among SWs difficult to implement.

COVERAGE (TARGET GROUP, GEOGRAPHICAL AND SERVICES)

• • •

Target groups: sex workers and their clients (especially mobile population) Geographically: nationwide Services: free distribution, condom social marketing through traditional outlets (pharmacies) and non-traditional outlets

ACHIEVEMENTS AND IMPACT

•

There has not been any nationwide study about this. The information provided here is from a study "Condom Usage and Behavior" implemented by DKT Vietnam - a leading contraceptive social marketing organization. The study was done from 12 April to 24 May 2004 aiming to understand the condom market and covers 1,415 participants, using the method of mapping high-risk targeted groups and mapping high-risk locations:

- 71 -

Annex 3 );> );> );>

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94% have used a condom, 6% never MSM with highest risk - over 50% do not use condom during their last MSM sex. Mobile businessmen (MB), male sex trade client (MSTC), MSM, IDU, and FSW do not always use protection with partners Condom usage last week - very low, except for PLW A and IDU FSW condom usage more closely reflect the frequency of intercourse IDU show the least rate of protection during intercourse 25% start wearing condom during sexual process, before ejaculation MSM (76%) do not use condom 1st time they have sex Condom usage for the first time is low, highest among MSTC & MB. Average age of first sex without condom is just above 19 PLWA understand importance of condom usage Others think condom use is not necessary with partner Those who have sex with male commercial partners believe condom use is important Only 56% FSW feel they 'must' use a condom 53% ofMSM think condoms are unnecessary A large number believe condom usage with sex workers as "necessary" not a "must" More than two thirds of males believe condom is necessary MSTC & MB groups tom between 'to use' and 'not to use' with irregular female partners Those who used a condom at first sex, with commercial partners considered it a "must".

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KEY LESSON LEARNT • • • Condom promotion strategies should not be isolated. It is effective only when it is part of a comprehensive picture ofHIV/AIDS control Using condoms is part of public awareness. Therefore, condom strategies need to be nationwide to reach every citizen. There have been some donor projects on condoms with huge budget but not so clear results. It is time for the Vietnamese government to coordinate them at all levels.

FUTURE PLANS TOWARDS NATIONWIDE SCALE UP

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National Harm Reduction Intervention Programme The National strategy on HIV/AIDS prevention and control in Vietnam until 2010 with a vision to 2020 with following comprehensive specific obJectIves: );>

100% of units and localities across the country shall incorporate HIV IAIDS prevention and control activities as one of priority objectives into their sOClo-economlC development programmes. To improve people's knowledge about HIV/AIDS transmission prevention; 100% of people living in urban areas and 80% of people living in rural and mountamous areas shall be able to correctly understand and identify ways of preventmg HIV/AIDS transmission.

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Annex 3 ~

To control HNIAIDS transmission from high-risk groups to the population through implementing comprehensive hann reduction intervention measures: all people with behavior at HNIAIDS infection risk shall be covered by intervention measures; 100% of safe injection and condom use when having risky sexual relations. To ensure the provision of care and appropriate treatment for HNIAIDS - infected people: 90% of HV/AIDS infected adults, 100% ofHNIAIDS infected pregnant mothers; 100 HNI AIDS infected or affected children shall be managed and provided with appropriate treatment, care and counseling, and 70% of AID patients shall be treated with specific drugs. To perfect the management, monitoring, surveillance and evaluation systems for the HNIAIDS prevention and control programme: 100% of provinces and cities shall be able to self evaluate - project the situation of development of HNIAIDS infection in their localities, 100% of HN testing shall be compliant with the regulations on voluntary testing and counseling. To prevent HNIAIDS transmission through medical services: ensuring 100% of blood units and blood products shall be screened for HN before transfusion at all levels; 100% of medical establishments shall strictly follow the regulations on sterilization, disinfection for HNIAIDS transmission prevention.

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