Mon, Hsu Hnin (Sandra)
Continnuum of Care Innovations for GMT in Burma/Myanmar
This research collaboration between the Center for Public Health and Human Rights (CPHHR), HIV/AIDS Alliance Myanmar, and partner community-based organizations (CBOs) aims to measure and overcome barriers to HIV testing, staging, and access to care through a set of 3 primary interventions for gay men, other men who have sex with men, and transgender individuals (GMT) in Myanmar. These interventions include (1) HIV self-testing innovations; (2) staging of HIV disease for those who are infected through point-of-care (POC) CD4 technology; and (3) training and capacity building of a cadre of peer health navigators for GMT to increase successful health system navigation and viral load monitoring for persons in need of ART or HIV disease management. The study will be implemented in a staged process, beginning with a formative/qualitative phase, baseline survey, and followed by the 3-step cascade interventions study. The study is intended to build local capacity for HIV prevention as well as to provide information on feasible and acceptible HIV care innovations for GMT populations.
Global Health Mentor: Chris Beyrer, MD, Director, Johns Hopkins Training Program in HIV Epidemiology and Prevention Science
My GHEFP was with Dr. Chris Beyrer from the Center for Public Health and Human Rights (CPHHR) on a wonderful project called Project Parasol in Yangon, Myanmar. The project—funded by amfAR (The Foundation for AIDS Research) and supported locally by the International HIV/AIDS Alliance Myanmar and the Myanmar Ministry of Health—aimed to explore the continuum of care for HIV among men who have sex with men (MSM) in Yangon, Myanmar. For clarification, the term MSM includes gay men, transgendered women (TGW), and other men who have sex with men, such as male sex workers.
Depending on who you ask, I either had the distinct advantage of fulfilling my MSPH practicum requirement in my home country (I am a—born, mostly-bred, and still fully—Burmese citizen), or the naïve disadvantage of limiting myself to my own country when I could be taking full advantage of the GHEFP offerings to practice public health anywhere else in the world. Granted, this was something I myself struggled with going into my placement. However, as soon as I arrived in Yangon and met with our local collaborators, I was reminded of how great a cause it was that I had signed up for, and how I, as a Myanmar national who could speak the language and actively (and literally!) translate my public health knowledge from Hopkins to the field, was actually in the perfect position to play a part in research that could benefit a long-stigmatized population in my own country. Perfect, no regrets—let’s dive right in.
If I had to take away one lesson from my placement, it would be the importance of key populations (i.e. MSM, transgendered persons injecting drug users, and sex workers) in informing national and international public health policies, particularly with HIV. Key populations are often already highly marginalized, even in many “developed” countries. Add to this a disease as controversial as HIV/AIDS, and you have the perfect storm of dual-stigmatization. In “developing” countries, where healthcare access is already limited, such dual-stigmatization could serve as an additional barrier to access. Furthermore, every country and each key population within that country has its unique sets of obstacles to access.
I had known from my experience growing up in primarily Buddhist Myanmar that the local attitude towards gay men and TGW was, for the most part, that of quiet, symbiotic acceptance. TGW played in local village “spirit” (or “nat”) festivals in which they serve as medium-wives to the supposedly male spirits (a tradition that dates back to pre-Buddhist times). During non-festival times, many TGW were hairdressers or makeup artists, and gay men fulfilled the role of fashion designers or tailors that served the sartorial needs of the community. Despite this, same-sex relationships and civil unions are still illegal and punishable by law in Myanmar, forcing many MSM to lead dual-lives, particularly when it came to healthcare. To further parse this phenomenon, I helped Project Parasol develop an electronic survey that was administered to participants, all of whom were recruited through a respondent-driven sampling (RDS) method. We also wanted to gauge the need for and acceptability of alternatives to currently available methods of HIV diagnosis, staging, and linkage to care among MSM in Myanmar. For this, we randomized participants to interventions at each of the above stages in the HIV care continuum: HIV self-testing (diagnosis), Point-of-Care CD4 testing (staging), and peer navigation (linkage to care).
My GHEFP with Project Parasol was the impetus I needed to transition my career towards an implementation science focus. A laboratory scientist by training, I enrolled in JHSPH’s Global Disease Epidemiology and Control program looking for a way to marry my molecular biology education with my personal background of having grown up in developing Southeast Asia. I found exactly this in Project Parasol, having dabbled in everything from designing the RDS recruitment coupons, developing an extensive electronic survey, writing the study protocol from scratch, creating and optimizing the laboratory methods, training staff, and even travelling to neighboring countries to pick up project supplies. I am incredibly grateful for this GHEFP opportunity, and even more so for the support of Dr. Beyrer, the research team at the CPHHR, and all the hard-working staff at the Project Parasol site office. I am excited to continue in this line work, and definitely ready—without regrets—to dive further in.
Entrance to the Project Parasol project office. Since the project office was going to have regular traffic of MSM and since same-sex relations are still punishable by law in Myanmar, we kept plain the external façade of the office plain in order not to attract potential attention from prosecuting authorities:
Going through the details of a mock-participant visit as a part of our 2-day in-office staff training after two days of more formal, didactic training in a nearby hotel. It was crucial for project staff to understand the “participant flow” in order to ensure that participants complete their visit in a timely and organized manner:
The Project Parasol study staff at the Project Office in Sanchaung Township, Yangon. Staff pictures includes the Project Coordinator, the Project Manager, the Coupon Manager, the Receptionist, the three Interviewers, a Peer Navigator, and the Laboratory Technician (and me).
One of the more mundane aspects of the job: individually-numbering the RDS recruitment coupons prior to the study roll-out:
Optimizing one of the laboratory procedures for Project Parasol in the Virology lab at the Department of Medical Research, Lower Myanmar. The procedure involved using rapid diagnostic tests on participant DBS samples to diagnose HIV. (I did a LOT of cutting in this Project!):