Implementing Comprehensive HIV/STI Programmes with Sex Workers Implementing Comprehensive HIV/STI Programmes with | Page 109

4 Condom and Lubricant Programming Box 4.4 Case example: Community-led condom promotion in Myanmar The Targeted Outreach Program (TOP), a programme of Population Services International (PSI) which began in 2003, provides sexual health services for female sex workers and men who have sex with men in Myanmar. TOP’s community-based approach engages community members as community outreach workers, field staff and eventually as management. Sex workers are involved in all aspects of planning, distributing, and promoting condoms. They identify hotspots for condom distribution as well as specific outlets and venues. Community outreach workers provide condoms to sex workers during outreach to complement PSI’s social marketing efforts. In addition, TOP builds social support for condom use among sex workers through programming at its 18 safe spaces (drop-in centres). TOP has been particularly successful in promoting the female condom. Community outreach workers provide one-on-one counselling on female condom use, including demonstrations using a female pelvic model. While TOP has found that proper use of the female condom requires several demonstrations, these skills-building sessions have successfully increased female condom use among female sex workers, and further demand generation activities are planned. In 2012 TOP distributed more than 1.2 million male condoms and over 110,000 female condoms to sex workers through community-led outreach. PSI also sells socially marketed condoms and lubricants in outlets close to sex work venues. Through a combination of free distribution and socially marketed condoms and lubricants, TOP ensures that sex workers and clients have access to high-quality, affordable, and accessible condoms and lubricants when and where they need them. Positive indicators of behaviour change and HIV prevalence among sex workers in Myanmar cannot be directly attributed to TOP but are highly correlated with its efforts. Surveys by the government, WHO and PSI estimate that HIV prevalence among female sex workers was 7.1% in 2012, a sharp decrease from 27.5% in 2004 and 18.4% in 2008. Destigmatizing condoms in the broader social environment Broad social support for condom use is needed in order for condoms to be used consistently in most commercial sex encounters. Condoms cannot be stigmatized or viewed as only for “risky sex”—it is essential that social values encourage the acceptance of condom use as a “sexual health” tool in both short-term and long-term sexual partnerships. As a result, in addition to working directly with sex workers and their clients, condom promotion programmes should also carry out activities for the general population in order to destigmatize condom use and create overall social support for condom use in all sexual partnerships. Media campaigns may be used to effectively promote condom use, decrease demand for unprotected sex and change social norms. Campaigns should provide consistent and complementary messaging across mass media, workplaces, health-service providers, and entertainment and sex work venues. Effective condom promotion to clients of sex workers relies on mass media promotion as clients are a highly dispersed group and very much part of the “general population”. As a result, they cannot be easily identified for intensive community-based interventions, such as those carried out for sex workers, men who have sex with men, people who use drugs and transgender people. Ideally, media promotional efforts are delivered through a partnership of organizations, including the national government, relevant NGOs, and private-sector condom companies. Countries such as Cambodia and Thailand, which have achieved significant reductions in heterosexual HIV transmission 87