An organization formed by sex workers for sex workers is making strides
in reducing the rate of infections.
Myanmar may have grabbed the world’s eye by opening
its borders and ushering in a foreign investment surge, but one story has
slipped quietly under the radar. The country has also significantly reduced the
rate of HIV infections in its sex worker population from its previous high of
40 percent in females 2005, according to Population Services International
(PSI) down to less than 10 percent today.
“Myanmar allowed sex worker-run programs to organize
and scale up over the last eight years using an empowerment-based model, rather
than a coercive testing model like the 100 percent condom programs in Thailand
and Cambodia. The success of the program in reducing HIV rates so dramatically
shows investing in sex worker-run programming works,” Andrew Hunter, program
and policy manager of the Asia Pacific Network of Sex Workers (APNSW), told The
Diplomat.
Myanmar’s HIV epidemic paralleled Cambodia’s, which peaked
at over 42 percent for brothel-based workers and 18 percent for entertainment
workers a decade ago, according to the National Center for HIV/AIDS,
Dermatology, STD (NCHADS), but its peer-led outreach did so with far less media
attention and international NGO fanfare.
Not Smothered by INGOs
Melissa Hope Ditmore, one of the foremost researchers
on worker-led initiatives in the sex industry, documented a case study of
Targeted Outreach Program (TOP), the largest HIV prevention program in Myanmar
initiated by PSI. The project has been unique for reaching up to 55 percent of
female sex workers and 70 percent of MSM out of the country’s estimated 60,000
sex workers. From NYC, Ditmore told The Diplomat “TOP was very successful
working against HIV and STIs. We know that community-lead initiatives are the
most effective.”
Kay Thi Win started working in 2004 with TOP in peer
education after being approached by them while employed as a sex worker. It was
a job she came to from economic hardship after her father died in 1998, while
she was studying at high school. Win’s mother could not support the family and
they lost their home. In 2000, a friend introduced her to sex work as a way to
support her family. Initially she told them she was working at a factory near
the Thai border, but now they know about her work and support her. According to
Raks Thai, an NGO that helps migrant workers, reports that migrants from
Myanmar comprise the largest groups of all migrants in Thailand due to limited
work options, but Win preferred to stay in the country.
She learned about the HIV epidemic sweeping the
country from TOP and how to use condoms for protection. Win told The Diplomat
from a conference on HIV in Bangkok that by 2012 the rate of HIV had declined
to just 7.1 for sex workers. Though no longer working for TOP, she still refers
sex workers to the project for health services.
Win now heads the AIDS Myanmar Association (AMA). AMA
is Burmese for “big sister.” Win says
that AMA is the only 100 percent sex worker-led organization in the country.
“AMA does health education, referral health services for HIV, and STI
counseling and treatment. [There is] sexual and reproductive health treatment,
also for our members who are getting sick,” said Win.
Ditmore explained “Sex workers have since started a
project that they direct, rather than being a subsidiary of another project. I
expect that if AMA continues its work, which is lead by sex workers, that it
will have great success and boost the reach of existing services to which they
refer others.”
AMA’s work has also caught the eye of the Association
of Women’s Rights in Development (AWID), the “only international feminist
membership organization.” Win was invited to speak to AWID in the beginning of
2012 and surprised the organization by saying that sex workers do not see
themselves as victims in need of rescue but are rather the empowered one in the
financial transaction. She now sits on AWID’s board as the first sex worker to
do so in its history.
Staying Safe in Sex Work
The feminist group awarded AMA a grant for teaching
financial skills to sex workers. “We believe that sex workers earn a lot of
income but do not know to how to save their money,” Win explained. “AMA
advocates with bank staff and managers to provide training for sex workers [on
the] banking system and information about bank savings.” Win adds, “Many of sex
workers do not have a National Identity card,” which she says is needed to open
a savings account.
Win thinks women working in entertainment clubs like
beer gardens and karaoke clubs (KTV) make “around $100 to $200 money per month
from drinking and pocket money (tips), with the salary.” Though no exact data
is reported, a large number of people live on $2 or less a day in Myanmar (49
percent of Cambodians do so), so this is a large sum of money.
“The first job is to be an entertainer and they are
paid about $30 a month, then they can be a sex worker. We also have ‘beer
girls’ [beer sellers]. They sell beer in a bar, but they don’t have to drink
beer. They are paid about $70 a month, but if they sell more beer, they get a
percentage of that. A ‘bar girl’ [a term used to describe women who provide
company to men visiting the bar] gets a salary of around $50 to $80 a month.”
Bar girls and beer sellers are also common in Cambodia.
“We also have karaoke and night club workers. If a sex
worker gets a drink at the club, she gets a percentage of the drink. If the
client gets a session at karaoke, he will often drink with her and she can [get
a percentage} of that as well. Massage workers don’t drink.”
Win notes that the clients are mostly locals. “There
are far fewer foreign men.” Of the foreigners, most are Asian businessmen.
“Sometimes local customers give more [money] than foreigners.”
“We have
condoms in brothels, massage places and KTV, but some of the KTV and massage
owners or managers do not want us to take them but we try to keep them with
girls and do advocacy toward that.” Win
says that “unofficially” condoms are used as evidence by police to arrest sex
workers but they are not used to prosecute them in court.
Street-based workers comprise the majority of AMA’s
members at about 70 percent. Win says rather than being the “poorer option,”
some choose this over club work, preferring to be more independent. “In Myanmar
sex workers from different cities and ethnicities, but [there are more]
Burmese. We have a significant number of male, transgender sex workers and
bisexuals.”
AMA is also supported by Myanmar Health and
Development Consortium (MHDC) through a grant from UNFPA. The UNFPA and UNDP
are working with AMA on a report on violence against sex workers. Dr. Hla Hla
Aye, UNFPA Assistant Representative, Myanmar Country Office explained in an
email to The Diplomat: “The decline of the HIV epidemic in Myanmar is due to
the coordinated efforts of all stakeholders and national leadership with
support from the UN and other actors together with community
empowerment…however, the prevalence is still high in IDU [injecting drug
users], SWs, and key affected populations still face the risk of stigma and
discrimination, but to a much lesser degree compared to ten years back.”
U.N. affiliate Global Commission on HIV and the Law
recommended in their report HIV and the Law that sex work be decriminalized to
improve the global HIV response, an initiative that APNSW, the regional sex
worker network wholly supports.
Tracey Tully, Advocacy & Communications Officer
for APNSW, told The Diplomat “We argue in favor of full decriminalization of
sex work, because sex workers have the right to work with other people. Sex
workers have the right to work with cleaners, receptionists, administrative
staff, security personnel, drivers and sex workers have the right to work for
establishments, to have bosses. To put it simply: ‘If my boss is criminalized,
I cannot use condoms.’ Any form of
criminalization will have a detrimental effect on sex workers’ ability to
negotiate safe sex and on community’s ability to respond effectively to the HIV
epidemic.”
Antiretroviral Therapy Drugs (ARV) in Myanmar
Access to treatment for HIV positive people in Myanmar
is a major problem, especially for people in rural areas. It affects not only
sex workers but also migrants living in Thailand.
“We would say
that access to Antiretroviral Therapy drugs (ARV) is still a challenge for
Myanmar however, a decentralization program for ARV has been initiated to
overcome access problems,” noted Dr. Hla Hla Aye of the UNFPA.
AMA is proactive here as well, providing ARV to its
members and a place (an apartment) for them to stay in Yangon while getting
medicine “because people need to stay a minimum of two weeks to a month,” said
Win.
While AMA has found a way to help its members, HIV
positive migrants face treatment obstacles. Brahm Press of Raks Thai Foundation
told The Diplomat they are highly mobile group and separated from their
networks at home, so tend to seek out sexual companionship. Though a survey
identified the use of sex workers’ services without condoms as a path of transmission
for Burmese fishermen, Press clarified that these tend to be “sweetheart”
relationships. Because of the perceived level of intimacy, condoms were not
used. “Serial monogamy without condoms has been identified as a path of HIV
infection.”
Unlike Myanmar, Thailand has national health insurance
with access to ARV, but migrants may not necessarily be able afford it. Press
said “Just recently the Thai government announced a change in the general
health insurance for migrants. They raised the price to 2,200 baht a year, plus
another 600 for the health examination, annually. This new rate includes ART
and, supposedly, all migrants, regardless of documentation status can
subscribe. The catch is, the government estimates they need 300,000 migrants to
enroll to break even. There is inconsistent implementation of the policy with a
number of hospitals not announcing the new policy; and at some locations,
migrants living with HIV who bought health insurance prior to the announcement
of the new policy were told that they still need to buy ARV out of pocket and
cannot buy into the new insurance until their old one expires. With a lack of
access to ART, some are advised to return to Myanmar, which has access problems
itself.”
Press explained that even though migrants may find
treatment at home, eventually they will want to return. “[Migrants] come from
rural areas and there are still not enough jobs in their home countries. So,
even if they do go home to start treatment, they will most likely return to
Thailand once they are strong, to continue working. And that raises other
concerns about adherence.”
Though solutions are being worked on for those needing
ARV treatment in Myanmar and Thailand, the means to economically support
oneself while on treatment appears to be another obstacle in resolving
Myanmar’s HIV situation.
Ditmore reported that programs like TOP prioritize
hiring sex workers who are HIV positive for peer education, but limited job
openings will likely be an issue for sex workers – who often also come from
rural areas – at least until Myanmar’s economy becomes stronger.
Michelle Tolson
