Progress update on cross border intervention in Myanmar-India-China borders.

 

Picture Getting familiar with new technologies in client tracking, Ruili, China

On May 25-29, 2015 CAHR Management, Alliance Secretariat and monitoring and evaluation (M&E) experts from Practice Centre on PWID and HCV hosted by International HIV/AIDS Alliance in Ukraine conducted a visit to the implementation sites across borders of Myanmar, India and China. Objectives of the visit were to observe the progress made in program development on the border areas, facilitate faster developments in program implementation and provide technical assistance on M&E which will help to track clients receiving services across the borders. Cross-border project is implemented in partnership of Alliance Myanmar, India HIV/AIDS Alliance and their partner organisation SASO, and AIDS Care China (ACC).

In Moreh (India-Myanmar border) clients will be referred for HIV testing, hepatitis testing, OST and STI testing. Referral system will be based on coupons given to the clients with reimbursement of their travel costs upon return from the service referral sites.

Referrals to HIV testing will be done to MSF in Moreh, MSI in Tamu and Hospital in Tamu. Each of these sites will be used as entry points for newly diagnosed and referred by the project HIV+PWID. Case manager specifically involved into the project will be contacted by the testing facilities each time the positive test occurs and if the client is willing to receive case management service. Case managers’ role would be to support the client to conduct the necessary diagnostics to determine the need for ART and to start ART if needed with follow up adherence support.

In Tamu (Myanmar – India border) Naloxone will be made available in each of the peddlers’ houses where the project will work as well as in Drop in-centre through overdose prevention and management training and Nalaxone distribution. SASO (partners of India HIV/AIDS Alliance) will be responsible for procuring, supplying Naloxone, providing training on overdose prevention, and refilling the stock when needs are reported by outreach workers.

Overall 300 PWID will be reached in the course of the project. Client tracking will be conducted with the use of smartphones with SyrEx cloud installed that will scan the clients’ cards containing bar codes linked with unique identifier code (UIC) (1-first letter of client name, 2-first letter of client mothers’ name, 3-first letter of client’s fathers’ name, 4-5-month of clients’ birth, 6-7-two last digits of client’s year of birth).

In Ruili (China-Myanmar border) AIDS Care China has its ‘Better Clinic’ that is providing NSP, OST and ART, as well as testing for HIV, TB and Hepatitis B and C. With cross-border project outreach activities to Myanmar neighbouring village of Zhuanjue have been established. Outreach services include distribution of 12 needles and 12 alcohol pads per PWID per visit. Condoms are available in the amount needed.

Outreach in Myanmar side near Muse by NGO Phoenix (sub-granted by Alliance Myanmar) will be done in 3 neighbouring villages – Salkand, Ton Khan and 105M. Also NSP will be based in Drop in centre in Muse in Phoenix office. During each contact PWID will receive 10 syringes, 10 alcoholic pads and 10 injection water bottles.

ACC will supply Naloxone to PWID on both side of the border, taken the restrictions in Naloxone prescription in Myanmar.

Better clinic in Lyaing (China-Myanmar border) right by the border with Myanmar was opened 7 months ago. It is providing needles and syringes, alcoholic pads, condoms, Naloxone, OST, ART. At the time of the visit the peer driven intervention (PDI) intervention was also going on to increase the number of clients. With the cross-border program 1 outreach worker was added to the project to work on Myanmar side in the Leiji town.

In the area of active conflict (101 area) which is not controlled by Myanmar government ACC is cooperating with Health Poverty International, which with the Global Fund funding is supporting 5 Drop in centres to implement needle and syringe exchange programme (NSP). ACC has trained PWID them to do PDI and is providing funding to reimburse the clients’ participation in 5 Drop in Centres.

M&E arrangement in the China-Myanmar border is to use fingerprints with SyrEx cloud.  On both sides smartphones with fingerprint reader will scan fingerprints and transfer them into codes (without possibility of reverse transition). Then the client information will be further passed to the SyrEx cloud. It is anticipated that some 400 PWID will be reached in Muse with Phoenix and Alliance Myanmar support and some 2000 PWID will be reached by ACC.

Why this cross-border intervention perspective and interesting?

Fast-track focused approach without borders. Due to drug trafficking routes and existing cultural patterns, drug use affects certain areas across the borders. Response programmes should not be fragmented country-wise, but rather focused in the areas with greatest concentrations of drug use and risks of HIV. Cross-border areas of India-Myanmar and Myanmar-China are such where drug use and HIV are the highest in each of the respective countries. Coordinated and focused approaches are needed to fit the needs and provide care continuum for the regularly migrating PWID population. Rather than supporting massive national interventions, focused approaches should concentrate in the most affected areas – within countries and between countries.

Access to clients not reached. It provides access to the PWID that are not accessing any harm reduction services due to the fact that neither the India side is providing services to them (restrictions related to providing services to the nationals only) not the Myanmar one. About 800 PWID are reached with harm reduction in Moreh, and additionally 300 PWID are crossing border from Myanmar regularly. This project is focusing on the Myanmar citizens.

Making benefit from ‘both worlds’: exchanging approaches and experiences. Despite proximity, the sites across the border have quite different regulations and restrictions, as well as different programme experiences. For example, Naloxone is strictly regulated in Myanmar, while it is on easily accessible with partner NGOs in China and India. At the same time, injecting water is not available in China near Myanmar border, while it is easy to buy one in Myanmar. Partners agreed to cooperate ‘exchanging’ injecting water to Naloxone. Similarly, programs’ elements across the border cross-fertilize each other: for example, Myanmar PWIDs are referred to China for Hepatitis rapid testing, which is not provided in Muse.

Continuum of services in the border area for this population is only possible with the strong linkages between the major program components, like NSP, referrals to OST, HIV testing and follow up, case management and ART adherence. Case management improves cascade for PWID and allows them to improve HIV testing and care for those who need it.

The project suggested very innovative and efficient M&E system that allows tracking clients’ paths between the borders and progression between multiple services offered by health facilities on both sides. The bar code and fingerprint entry techniques with referral systems for HIV testing, OST, ART will allow to see how the clients flow from outreach to testing and treatment, what preference they have as per institutions, and what the real treatment cascade is and how to improve it.