End of Project Review of  
“Social Marketing and Targeted Communications for
HIV and AIDS Prevention Among Most–at–Risk Populations in
Burma, China, Lao, and Thailand”
October 2007–September 2010
Final Report
Review Team
David Lowe, Independent Consultant
Nithya Mani, Independent Consultant
Ken Swann, Independent Consultant
Thu Van Dinh, USAID/Washington
Panus NaNakorn, USAID/RDMA
Theresa Outlaw, USAID/RDMA
Cameron Wolf, USAID/RDMA
USAID/Regional Development Mission Asia (USAID/RDMA)
March 2010
Table of Contents 
Acronyms..............................................................................................................................................iv
Executive summary............................................................................................................................. vi
1. The context .................................................................................................................................... 1
1.1 Background...........................................................................................................................1
1.2 Methodology.........................................................................................................................2
1.3 Limitations of the assessment.............................................................................................3
2. Key overarching findings....................................................................................................... 4
2.1 PSI Agreement objectives....................................................................................................4
2.1.1 Increase access to prevention interventions for MARPs............................................4
2.1.2 Increase access to care and support for PLHA ............................................................5
2.1.3 Increase access to strategic information .......................................................................6
2.1.4 Strengthen the enabling environment ..........................................................................6
2.2 Other key findings ...............................................................................................................7
2.2.1 Innovation.........................................................................................................................7
2.2.2 Leverage of additional funding and a broader public health focus .........................8
2.2.3 Relationship of PSI’s work to the Global Health Initiative........................................8
2.2.4 Replication and sustainability........................................................................................8
3. Burma ........................................................................................................................................... 10
3.1 HIV prevalence in Burma .................................................................................................10
3.2 Overview of PSI/Burma program....................................................................................10
3.3 Prevention ...........................................................................................................................10
3.3.1 Outline of the Burma prevention program ................................................................10
3.3.2 Key achievements ..........................................................................................................11
3.3.3 Strengths and facilitating factors.................................................................................18
3.3.4 Challenges and barriers ................................................................................................20
3.3.5 Replication and sustainability......................................................................................21
3.4 Strategic Information.........................................................................................................22
3.4.1 Outline of key strategic information activities ..........................................................22
3.4.2 Key achievements ..........................................................................................................23
3.4.3 Strengths and facilitating factors.................................................................................26
3.4.4 Challenges and barriers ................................................................................................27
3.4.5 Replication and sustainability......................................................................................27
3.5 Program management .......................................................................................................27
3.5.1 Outline of program management................................................................................27
3.5.2 Key achievements ..........................................................................................................28
3.5.3 Strengths and facilitating factors.................................................................................29
3.5.4 Challenges and barriers ................................................................................................29
3.5.5 Replication and sustainability......................................................................................29
3.6 Burma: TB program ...........................................................................................................30
3.6.1 Outline of the Burma TB program ..............................................................................30
3.6.2 Key achievements ..........................................................................................................31
3.6.3 Strengths and facilitating factors.................................................................................31
3.6.4 Challenges and barriers ................................................................................................32
3.6.5 Replication and sustainability......................................................................................32
4. China ........................................................................................................................................34
i
4.1 HIV prevalence in China...................................................................................................34
4.2 Overview of PSI/China program .....................................................................................34
4.3 Prevention ...........................................................................................................................35
4.3.1 Outline of the PSI/China HIV prevention program..................................................35
4.3.2 Key achievements ..........................................................................................................36
4.3.3 Strengths and facilitating factors.................................................................................39
4.3.4 Challenges and barriers ................................................................................................39
4.3.5 Replication and sustainability......................................................................................40
4.4. Strategic Information.........................................................................................................41
4.4.1 Outline of key strategic information activities ..........................................................41
4.4.2 Key achievements ..........................................................................................................43
4.4.3 Strengths and facilitating factors.................................................................................44
4.4.4 Challenges and barriers ................................................................................................44
4.4.5 Replication and sustainability......................................................................................45
4.5 Program Management.......................................................................................................45
4.5.1 Outline of program management................................................................................45
4.5.2 Key achievements ..........................................................................................................45
4.5.3 Strengths and facilitating factors.................................................................................47
4.5.4 Challenges and barriers ................................................................................................48
4.5.5 Replication and sustainability......................................................................................49
5. Lao ................................................................................................................................................ 51
5.1 HIV prevalence in Lao.......................................................................................................51
5.2 Overview of PSI/Lao program .........................................................................................51
5.3 Prevention ...........................................................................................................................51
5.3.1 Outline of the PSI/Lao HIV prevention program......................................................51
5.3.2 Key achievements ..........................................................................................................52
5.3.3 Strengths and facilitating factors.................................................................................56
5.3.4 Challenges and barriers ................................................................................................56
5.3.5 Replication and sustainability......................................................................................57
5.4 Strategic information .........................................................................................................57
5.4.1 Outline of key strategic information activities ..........................................................57
5.4.2 Key achievements ..........................................................................................................57
5.4.3 Strengths and facilitating factors.................................................................................60
5.4.4 Challenges and barriers ................................................................................................60
5.4.5 Replication and sustainability......................................................................................61
5.5 Program Management.......................................................................................................61
5.5.1 Key achievements ..........................................................................................................61
5.5.2 Strengths and facilitating factors.................................................................................62
5.5.3 Challenges and barriers ................................................................................................63
5.5.4 Replication and sustainability......................................................................................65
6. Thailand ....................................................................................................................................... 66
6.1 Overview of HIV in Thailand...........................................................................................66
6.2 Overview of PSI/Thailand program ................................................................................66
6.3 Prevention ...........................................................................................................................66
6.3.1 Outline of Thailand prevention program...................................................................66
6.3.2 Key achievements ..........................................................................................................67
6.3.3 Strengths and facilitating factors.................................................................................68
ii
6.3.4 Challenges and barriers ................................................................................................68
6.3.5 Replication and sustainability......................................................................................68
7. Future Directions ........................................................................................................................ 69
7.1 Prevention .........................................................................Error! Bookmark not defined.
7.1.1 Burma ............................................................................Error! Bookmark not defined.
7.1.2 China..............................................................................Error! Bookmark not defined.
7.1.3 Lao..................................................................................Error! Bookmark not defined.
7.1.4 Thailand ........................................................................Error! Bookmark not defined.
7.1.5 Regional.........................................................................Error! Bookmark not defined.
7.2 Strategic information .......................................................Error! Bookmark not defined.
7.2.1 Burma ............................................................................Error! Bookmark not defined.
7.2.2 China..............................................................................Error! Bookmark not defined.
7.2.3 Lao..................................................................................Error! Bookmark not defined.
7.2.4 Regional.........................................................................Error! Bookmark not defined.
7.3 Program management .....................................................Error! Bookmark not defined.
7.3.1 Burma ............................................................................Error! Bookmark not defined.
7.3.2 China..............................................................................Error! Bookmark not defined.
7.3.3 Lao..................................................................................Error! Bookmark not defined.
Annex 1: Key documents reviewed ................................................................................................. 70
Annex 2: Site visits/organizations visited ....................................................................................... 72
Annex 3: Map of current locations of the TOP program (Burma)............................................... 74
Annex 4: PSI/Burma TOP activity data ........................................................................................... 75
Annex 5: Strategic information activities for PSI/Burma and PSI Lao........................................ 78
Annex 6: PSI results by PEPFAR core indicators and project objectives.................................... 80
iii
Acronyms 
AEM   Asian Epidemic Model
AIDS   Acquired immunodeficiency syndrome
ART   Antiretroviral therapy
ARV   Anti–Retroviral
BCC   Behavioral change communication
CA   Cooperating Agency
CBO   Community–based organization
CDC   Center for Disease Control
CHAS   Center for HIV/AIDS and STIs (Ministry of Health, Lao PDR)
CPP   Comprehensive Prevention Package
CPS   Comprehensive Package of Services
DiC   Drop–in center
FHI   Family Health International
FSW   Female sex worker
FY   Financial year
GFATM The Global Fund for AIDS, Tuberculosis and Malaria
HIV   Human immunodeficiency virus
HPI   Health Policy Initiative
IDU   Injecting drug user
INGO   International Non–governmental organization
MARP   Most–at–risk population
MMT   Methadone maintenance therapy
MoH   Ministry of Health
MSM   Men who have sex with men
NSP   National Strategic Plan for HIV and AIDS
NCAIDS National Center for AIDS and Infectious Diseases  
NGO   Non–governmental organization
PHB   Public Health Bureau
PLHA   People living with HIV or AIDS
PE   Peer Educator
PSB   Public Security Bureau
PSI   Population Services International
RBT   Routine Behavioral Tracking
RDMA   Regional Development Mission, Asia
RMB (CNY) Renminbi (Chinese currency)  
SQH   Sun Quality Health (network of private providers in Burma)
STI   Sexually transmitted infections
TA   Technical assistance
TB   Tuberculosis
TOP   Targeted Outreach Program  
TRaC   Tracking Results Continuously
UN   United Nations
UNAIDS Joint United Nations Program on HIV and AIDS
UNDP   United Nations Development Program
UNICEF   United Nations Childrenʹs Fund
USAID   United States Agency for International Development
USG   United States Government
iv
VCT   Voluntary counseling and testing
WHO   World Health Organization
v
Executive summary 
This report details findings of an end of project assessment of the implementation of
USAID/RDMA’s cooperative agreement with PSI for ‘Social marketing for STI/HIV prevention
among high risk groups in the Mekong region, FY08‐FY10. The project is funded over a three
period, with allocations by country as follows – Burma: HIV $3.6 m, TB $1 m; China: $2.6 m; Lao:
$1 m; and Thailand: $0.2 m.  
The strategic goal of the project is to reduce the spread of HIV and STI among most at risk
populations (MARPs) including female sex workers (FSW) and their clients, injecting drug users
(IDU), and men who have sex with men (MSM), including transgenders (TG). The project’s main
objective is to increase access to the Comprehensive Package of Services (CPS) by MARPS. Key
achievements in relation to the project’s intermediate objectives are as follows:  
Objective 1: Increase access to prevention interventions for MARPs
All of the MARPs targeted by PSI are hard to reach because of social marginalization and all have
relatively high rates of HIV, although this varies by MARP and geographic location. PSI’s
programs in each country have resulted in significantly increased access to prevention
interventions by MARPs. Depth of penetration in accessing MARPs has been high.  
PSI’s social marketing activities have significantly grown the size of the condom markets and
established condom buying habits among MARPs and others. Since 2007, sales and free
distribution of condoms and lubricant to MARPs, their partners and the general population have
continued to grow significantly. PSI recognizes the need to encourage new private sector entrants
into the condom market, (which is occurring in Lao), to ensure long term sustainability, whilst
ensuring that affordable condoms are available to the poor and most vulnerable.  
Periodic behavioral surveys conducted by PSI in each country found evidence of positive
behavior change in the most at risk populations targeted. These outcomes include higher levels of
condom use and consistent condom use among MSM and FSW, and in China decreased sharing
of needles and syringes among IDU. PSI behavioral data for most MARPs indicates that
statistically significant levels of behavior change are achieved when MARPs are exposed to more
elements of the comprehensive prevention package. This ‘dosage’ effect confirms that the
comprehensive prevention package approach is both appropriate and needed.  
Increased safe behavior by MARPs may contribute to the program’s strategic goal of reducing the
spread of HIV and STIs among MARPS. However, there is insufficient data at this point in time to
demonstrate whether this higher level impact is being achieved by PSI.  
Objective 2: Increase access to care and support for PLHA
PSI’s promotion and provision of VCT services has increased access to HIV testing, enabling
MARPs to know their HIV status and be referred to care, support and treatment services.
However, the uptake of HIV counseling and testing is quite low, and most MARPs do not know
their HIV status. PSI promotion and provision of STI diagnostic and treatment services for
MARPs has increased access to client‐friendly STI services. As with VCT, the uptake of STI
clinical services has generally been low. This points to the need to address demand side issues as
well as supply side issues. The introduction of rapid testing for VCT significantly increased VCT
uptake among MARPs in China and Lao. PSI’s social marketing of pre‐packaged, branded STI
vi
treatment kits through DiCs and the private sector has increased MARP access to appropriate and
quality treatment regimens at an affordable price.  
USAID support for PSI/Burma’s TB program has increased access to free TB treatment on a
national scale, with a focus on the poor. However, integration of HIV and TB has been limited as
only a minority of TB cases are having HIV tests due to policy settings which limit the places
where HIV testing can be performed.  
Access by HIV positive MARPs to care, support and treatment services provided by PSI’s partner
organizations has been limited in some countries, particularly Burma, because of the small
number of treatment places available. In high prevalence settings, PSI increased its focus on the
care and support needs of PLHA. While there are linkages with care, support and treatment
services, the capacity of all programs to ensure a seamless continuum of prevention to care,
support and treatment has been insufficient.  
Objective 3: Increase access to strategic information
PSI’s strong emphasis on strategic information highlights the value the organization places on
evidence‐based programming; quality assurance methods are built into its data collection
systems; good internal capacity has been built; and the results of research are turned into
program action. Areas where performance has been mixed are in using strategic information for
advocacy on policy change and program issues at the national and sub‐national levels; more
regular sharing and dissemination of results to external partners; and greater involvement of
MARP communities in evidence‐based decision making.  
Objective 4: Strengthen the enabling environment
PSI’s work has contributed to strengthening the enabling environment in a number of ways.
There has been significant capacity building of the private sector in social marketing of condoms
and other health products and in social franchising of health services to improve access by the
poor. The capacity of MARPs to design and implement prevention programs has increased
significantly in all countries. Capacity building of peers has resulted in a self‐confidence that has
reduced internalized or self‐stigma and facilitated community mobilization. The capacity of PSI
programs in all countries to ensure a seamless continuum of prevention to care, support and
treatment needs continued strengthening.  
PSI’s approach has been to foster peer led community mobilization approaches in its work with
MARPs. As an INGO, PSI has been able to more readily work with marginalized community
groups than would be the case for local organizations in the context of government antipathy
towards civil society. The provision of high profile HIV services for MARPs has resulted in the
health and broader social needs of MARPs becoming more visible to local and national health
officials and other partners, which has helped to combat stigma and discrimination and further
MARP visibility in national strategies and Global Fund proposals. Where PSI prevention
programs have had a strong focus on the needs of PLHA, particularly in Burma, this has resulted
in a more open and supportive environment for PLHA, which helps to reduce stigma faced by
PLHA from their MARP peers.  
Other overarching findings are:  
Innovation has been a strong feature of PSI’s programming in all countries. This has included use
of financial incentives to reach program targets, promotion of female condoms to MSM, use of
vii
viii
information technologies to promote VCT, use of peer progression promotion structures for
prevention program staff, and use of GIS technology for measuring program coverage in relation
to hot‐spots. Innovation has also been a strong feature of PSI’s approach to strategic information.
This includes the development of client unique identifier codes to facilitate measurement of the
number of individuals reached and periodic surveys to track behaviors and the determinants of
behavior which are then used to refine interventions and BCC messaging. Innovative use of social
franchising has also been a strong feature of PSI’s work.  
PSI has been very successful in leveraging other donor funds for HIV and other public health
work. Leverage of funds has allowed an expansion of USAID‐developed models, resulting in
greater access by MARPs to prevention interventions and care, support and treatment.
Additional funding has enabled PSI to develop a portfolio of other public health work which in
turn has allowed for a more integrated approach such as with HIV/TB work.  
Public health officials in the four countries are increasingly seeing the value of community led
approaches to HIV prevention. However, the broader political environments in three of the four
countries are not encouraging for the development of civil society. Considerable work remains to
be done in documenting and advocating for this approach and in CBO organizational
development.
PSI’s social franchising of health services has good sustainability potential as it has been
accompanied by ongoing capacity building of pharmacies, medical practitioners and community
health workers.  
Replication of PSI’s programming has been occurring in a number of ways. As additional funds
are mobilized from other donors, this has allowed PSI’s existing programs to be replicated in new
sites. The elements of USAID’s Comprehensive Prevention Package model, being implemented
by PSI, has also had a significant influence on the prevention programming of other donors and
in the programming approach reflected in Global Fund proposals. More broadly, the HIV and
AIDS National Strategic Plans of all four countries now prioritize MARPs and the prevention
approaches in these strategies have been strongly influenced by the CPP. This type of replication
significantly strengthens sustainability.  
1. The context 
1.1 Background 
A review of PSI’s cooperative agreement “Social Marketing for STI/HIV Prevention among High
Risk Groups in the Mekong Region” (2007–2010) was carried out from 4 January to 5 February
2010.  
The strategic goal of the project is to reduce the spread of HIV and STI among most at risk
populations (MARPs) including female sex workers (FSW) and their clients, injecting drug users
(IDU), and men who have sex with men (MSM), including transgenders (TG). The project’s main
objective is to increase access to the Comprehensive Package of Services (CPS) by MARPS. Four
underlying objectives include:
1. Increase access to prevention interventions for MARPs
2. Increase access to care and support for PLHA
3. Increase access to strategic information
4. Strengthen the enabling environment  
The project is funded over a three year period (FY2008–FY2010) and includes:
 Burma (HIV: $3.6m: + TB: $1m)
 China ($2.6m)  
 Lao ($1m)  
 Thailand ($0.2m)
The key objective of this review of USAID/RDMA’s cooperative agreement with PSI was to
determine the strengths and weaknesses of the program in order to inform the USAID Regional
Development Mission’s Asia (RDMA) program planning and design of future HIV technical
capacity building activities in non–presence countries in Asia. The primary focus of the
assessment was on the USAID–supported activities of PSI. However, as PSI works with other
USAID Cooperating Agencies (CAs), the assessment also examined the work of PSI and other
CAs in STI and HIV prevention and social marketing activities in Burma, China, Lao PDR and
Thailand related to PSI’s current activities as well as activities in Thailand that were initially
funded through the agreement and were later transitioned (MSM/TG) or discontinued (IDU).  
The Scope of Work (SOW) for the assessment set out the following primary areas for
investigation:
1. Have country–level activities improved the quality of preventive products ‐‐ condoms,
lubricant, sexually transmitted infection (STI) treatment kits ‐‐ available to MARPs?
2. Have country–level activities improved the availability and access for MARPs to these
preventive products?
3. Have country–level activities helped to build the private sector’s capacity to provide HIV/STI
products for MARPS?
4. Have country–level activities built the capacity of private and/or public sector HIV/STI
service providers (i.e. on voluntary HIV counseling and testing (VCT) provision, STI
screening, STI treatment)?
5. Has PSI been actively engaged in participating in the development of best practice models on
HIV/STI prevention, care, and support with national partners/stakeholders?
6. Has PSI been actively involved in supporting the country to mobilize funding to support the
scale up and sustainability of interventions beyond USAID available funds?
1
7. Has PSI been actively participating in assisting the national program to ensure country–level
activities are appropriately ‘following the epidemic’?
1.2 Methodology 
Assessment activities began with a review of documents (scope of work, planning, reporting,
program performance and technical documents) provided by USAID/RDMA and PSI.
Information gained from the document review served as a basis to formulate questions for key
informants including PSI project staff, government officials, project beneficiaries and other
stakeholders.
The seven–person assessment team carried out site visits to PSI interventions in Burma, China,
Lao and Thailand. The team was made up of three independent consultants and four USAID staff,
three of whom work in USAID/RDMA. The team split up for site visits with one team visiting
Burma and Lao, and the other team visiting China (Yunnan and Guangxi provinces) and
Thailand. During the visits each team met with key informants including implementing partners,
government officials, and project beneficiaries—female sex workers (FSW), injecting drug users
(IDU), men who have sex with men (MSM), and transgenders (TG). Site visits were for the
following durations:  
• Lao PDR: 3 days
• Burma: 5 days
• China: 8 days
• Thailand: 1 day
Documents
A variety of documents from both PSI and USAID/RDMA were available for review (see Annex
1). Annual reports, work plans, proposals, trip reports, research reports, and site fact sheets from
the project shed light on progress over time. Other materials provided information on HIV
prevalence trends, HIV and AIDS services, social marketing of HIV prevention commodities, and
behavior change communication strategies employed by PSI.  
Data
Data available to the assessment team included data from PSI’s TRaC (Tracking Results
Continuously) surveys which provided information on behaviors of MARPs, results of service
delivery, and exposure to PSI’s programs. TRaC results as well as routine program monitoring
data and project mapping shed light on the effectiveness of PSI’s interventions and activities.
Interviews
In–depth interviews with PSI management and staff, government officials, project partners and
beneficiaries were a major source of information for the assessment.  
Site visits
The assessment team conducted site visits (see Annex 2 for a list of organizations visited) to
locations where PSI implements interventions such as drop‐in center activities, peer education,
community outreach, VCT, STI, TB treatment and social marketing. Locations for site visits were
chosen in consultation with RMDA and PSI. The team also met with government, UN and other
INGO partners as well as project staff and beneficiaries.  
2
1.3 Limitations of the assessment 
Given the breadth of evaluation questions and themes, beneficiary groups and the geographic
coverage in each country, there were limits to the depth of inquiry the two teams could complete
in the time available. The size and complexity of PSI’s interventions in Burma, China, Lao and
Thailand, and the brevity of the site visit period somewhat constrained the depth of information–
gathering. In–depth discussions with beneficiaries were limited by time considerations.  
3
2. Key overarching findings 
This section synthesizes key overarching findings of this end of project review with a particular
emphasis on Burma, China and Lao where the PSI regional project currently has USAID‐
supported activities. The first set of key findings are grouped under the four objectives PSI was
tasked to achieve in their funding proposal to USAID/RDMA over the three years of this
agreement extension, FY08‐FY10. These key findings are outlined in sections 2.1.1 through 2.1.4.
Other key findings of the review are grouped under a range of additional thematic areas in
sections 2.2.1 through 2.2.4. Data to support the findings are contained in each of the chapters
outlining the work of PSI in the four countries and in Annex 6: PSI results by PEPFAR core
indicators and project objectives.  
2.1 PSI Agreement objectives 
2.1.1 Increase access to prevention interventions for MARPs
All of the MARPs targeted by PSI are hard to reach because of social marginalization and all have
relatively high rates of HIV, although this varies by MARP and geographic location. PSI’s
programs have resulted in significantly increased access to prevention interventions by MARPs.
Depth of penetration in accessing MARPs has been high. However, the extent to which PSI’s
prevention programs have been able to access MARPs also varies by country and by population.
Some MARP populations are more difficult to reach than others. For example, in China IDU are
particularly difficult to reach as they are well practiced in hiding from law enforcement officials.
Growth in access to prevention interventions has been highest in Burma which has the largest
scale PSI prevention program of the four countries due to a higher level of USAID funding and a
higher level of leveraging of other donor funds. In Burma, coverage of FSW is higher compared
to MSM as a larger number of FSW can be reached at the places where they meet clients, whereas
MSM are generally more hidden.  
Among each of the MARPs being targeted there are sub‐populations that are more difficult to
access than others (e.g. low‐fee sex workers in China, hidden MSM, IDU hiding from law
enforcement officials). This highlights the importance of programs examining who they reach and
how they can increase coverage to the most at risk and hard to reach.  
In Burma and Lao, PSI conducts large scale national social marketing of condoms and water
based lubricants through extensive networks of private sector traditional and non‐traditional
outlets. In Burma, PSI has around 80% of the national condom market and in Lao 58% of the
national market. Since 2007, sales and free distribution of condoms and lubricant to MARPs, their
partners and the general population have continued to grow significantly. PSI’s social marketing
activities have significantly grown the size of the condom market and established condom buying
habits among MARPs and others.  
In some countries there has been overlap between the work of PSI and other USAID CAs working
with the same MARP. Usually this has been adequately dealt with by one CA being responsible
for one geographic area or segment of the MARP population, with the other CA being
responsible for another area or segment. There has been some duplication, but this has been
minimal.  
4
Beyond measuring increased access to prevention interventions, PSI routinely tracks behavioral
outcomes among the populations they serve. Periodic behavioral surveys conducted by PSI in
each country found evidence of positive behavior change in the most at risk populations targeted.
These outcomes include higher levels of condom use and consistent condom use among MSM
and FSW and in China decreased sharing of needles and syringes among IDU. PSI behavioral
data for most MARPs indicates that statistically significant levels of behavior change are achieved
when MARPs are exposed to more elements of the comprehensive prevention package. This
‘dosage’ effect confirms that the comprehensive prevention package approach is both appropriate
and needed.  
As is common throughout the region, PSI’s behavioral data demonstrates that consistent condom
use by MARPs is higher with casual and commercial partners than for regular partners. PSI has
recognized the need to particularly focus on increasing consistent condom use with regular
partners.  
Increased safe behavior by MARPs may contribute to the program’s strategic goal of reducing the
spread of HIV and STIs among MARPS. However, there is insufficient data at this point in time to
demonstrate whether this higher level impact is being achieved by PSI. Epidemiological
modeling indicate that quite high program coverage levels as well as program intensity need to
be achieved for changes in behavior to result in a reduction in incidence, particularly in high
prevalence settings. This emphasizes the importance of continued scale‐up of prevention
programs for MARPs.  
2.1.2 Increase access to care and support for PLHA
Although PSI’s contractual obligations to USAID centered around delivering a prevention
program, a key objective has been to increase access to care and support for PLHA. PSI has
recognized the importance of providing a continuum of prevention to care, support and
treatment services.  
PSI’s promotion and provision of VCT services has increased access to HIV testing, enabling
MARPs to know their HIV status and be referred to care, support and treatment services.
However, as is common with MARP prevention programs in the region, the uptake of HIV
counseling and testing is quite low, and most MARPs do not know their HIV status.  
PSI promotion and provision of STI diagnostic and treatment services for MARPs has increased
access to client‐friendly STI services. Although MARP utilization of STI services is mostly at
higher levels than utilization of VCT, the uptake of STI clinical services has generally been low,
especially in view of high STI rates. Low utilization rates of VCT and STI services points to the
need to address demand side issues as well as supply side issues. The introduction of rapid
testing for VCT significantly increased VCT uptake among MARPs in China and Lao. PSI’s social
marketing of pre‐packaged, branded STI treatment kits through DiCs and the private sector has
increased MARP access to appropriate and quality treatment regimens at an affordable price.
There is a need to continue to strengthen quality assurance systems for STI clinical services,
particularly in Lao.  
In Burma, there has been some integration of HIV and TB clinical services in PSI clinics through
the provision of TB screening. USAID support for PSI/Burma’s TB program has increased access
to free TB treatment on a national scale, with a focus on the poor. However, integration of HIV
5
and TB has been limited as only a minority of TB cases are having HIV tests due to policy settings
which limit the places where HIV testing can be performed.  
Access by HIV positive MARPs to care, support and treatment services provided by PSI’s partner
organizations has been limited in some countries, particularly Burma, because of the small
number of treatment places available. In high prevalence settings, PSI increased its focus on the
care and support needs of PLHA. While there are linkages with care, support and treatment
services, the capacity of all programs to ensure a seamless continuum of prevention to care,
support and treatment has been insufficient.  
2.1.3 Increase access to strategic information
PSI’s program is evidence based and data driven. Routine monitoring and evaluation data,
including data collecting using unique identifier codes (UIC), have been continuously analyzed
and used in refining project design and implementation. Periodic TRaC surveys have allowed for
good assessments of intervention outcomes over time with respect to how behaviors, attitudes,
knowledge, and beliefs have changed in target populations. These surveys collect information
that demonstrates attribution of improvements in health outcomes directly to PSI programs.
Behavioral determinants identified from TRaC surveys are used to create HIV Marketing Plans
and an audience profile for each target group which are used to guide how prevention
interventions are delivered. Prevention messages are informed by this systematic research on the
determinants of behavior. Qualitative research has also been conducted to supplement the
quantitative oriented TRaC surveys.  
In Burma and Lao, PSI regularly conducts Project MAP (Measuring Access and Performance)
surveys to track product availability in all project sites. For example, this is used to measure the
location of condom availability in proximity to hot spots. PSI also regularly utilizes GIS mapping
to geographically depict its program components, which allows for a quick snapshot of
geographical program coverage. In China, PSI, together with other CAs, is leading a process for
routine behavioral tracking for MSM and FSW programs.
PSI’s strong emphasis on strategic information highlights the value the organization places on
evidence‐based programming; quality assurance methods are built into its data collection
systems; good internal capacity has been built; and the results of research are turned into
program action. Areas where performance has been mixed are in using strategic information for
advocacy on policy change and program issues at the national and sub‐national levels; more
regular sharing and dissemination of results to external partners; and greater involvement of
MARP communities in evidence‐based decision making.  
2.1.4 Strengthen the enabling environment
PSI’s work has contributed to strengthening the enabling environment in a number of ways:  
Capacity building: There has been significant capacity building of the private sector in social
marketing of condoms and other health products and in social franchising of health services to
improve access by the poor. Social franchising of health services in Burma through the Sun
Quality Health and Sun Primary Health networks has been accompanied by capacity building
and development of quality assurance systems for private medical practices and community
health workers. The capacity of MARPs to design and implement prevention programs has
increased significantly in all countries. Capacity building of peers has resulted in a self‐
6
confidence that has reduced internalized or self‐stigma and facilitated community mobilization.
There has been insufficient capacity building of the technical expertise of clinical staff. The
capacity of PSI programs in all countries to ensure a seamless continuum of prevention to care,
support and treatment needs continued strengthening.  
Community mobilization: PSI’s approach has been to foster peer led community mobilization
approaches in its work with MARPs. With the exception of Thailand, this has been occurring in
the context of government antipathy towards civil society. As an INGO, PSI has been able to
more readily work with marginalized community groups than would be the case for local
organizations. Although programs are largely PSI implemented, they are characterized by
community development and community mobilization approaches. In China, PSI has been able
to provide sub‐grants to nascent CBOs and strengthen their capacity for implementation and
working with government community based HIV programs.  
Increased access to services: The provision of STI and VCT services by PSI has ensured that
MARPs have easy access to non‐discriminatory services that are, especially for STIs, clinically
appropriate to their needs. Facilitated referrals to care, support and treatment services have
increased MARP access by addressing discriminatory health service practices.  
Social recognition: the provision of high profile HIV services for MARPs has resulted in the
health and broader social needs of MARPs becoming more visible to local and national health
officials and other partners. This social recognition helps to combat stigma and discrimination
and further MARP visibility in national strategies and Global Fund proposals.  
Safe spaces: DiCs for MARPs represent a social recognition of their needs and provide a safe
space which helps increase social confidence and reduce self‐stigma. Where PSI prevention
programs have had a strong focus on the needs of PLHA, particularly in Burma, this has resulted
in a more open and supportive environment for PLHA, which helps to reduce stigma faced by
PLHA from their MARP peers.  
2.2 Other key findings 
2.2.1 Innovation
Innovation has been a strong feature of PSI’s programming in all countries. With variation
between countries, incentives are used in order to reach program goals. For example, payments
are made to MSM peer educators in Lao based on the number of VCT referrals, and to the poorest
TB patients in Burma to support transportation costs, with the aim of achieving improved
treatment adherence. Innovation has also been used in prevention program design including
promotion of the female condom to MSM, use of text messaging to mobile phones to promote
VCT, use of peer progression promotion structures for prevention program staff, and use of GIS
technology for measuring program coverage in relation to hot‐spots.  
Innovation has also been a strong feature of PSI’s approach to strategic information. This includes
the development of client unique identifier codes to facilitate measurement of the number of
individuals reached and periodic surveys to track behaviors and the determinants of behavior
which are then used to refine interventions and BCC messaging.  
Innovative use of social franchising has also been a strong feature of PSI’s work. This has
included social franchising of a range of health products through traditional and non‐traditional
7
outlets and the development of private medical and primary health social franchising networks
in Burma. PSI’s social franchising work has resulted in a significant private sector involvement in
HIV and other public health work which has considerable potential for sustainability.  
2.2.2 Leverage of additional funding and a broader public health focus
PSI has been very successful in leveraging other donor funds for HIV and other public health
work. This means that PSI has become less reliant on USAID for funding. This provides a more
stable financial base for ongoing operations. Leverage of funds has allowed an expansion of
USAID‐developed models, resulting in greater access by MARPs to prevention interventions and
care, support and treatment. PSI has, to varying degrees in the different countries, been able to
build up a portfolio of other public health work. This has allowed for a more integrated approach
such as with HIV/TB work. Leverage of other donor funding has enabled PSI to apply its
strengths in prevention programming, research, social marketing and social franchising to a
broader portfolio of public health work.  
2.2.3 Relationship of PSI’s work to the Global Health Initiative
The US Government has announced a new Global Health Initiative (GHI), a six year $63 billion
investment that commenced in FY2009, that will provide a common vision for integrated global
health programming with an emphasis on health systems strengthening. PSI’s work relates to a
number of the GHI goals and principles. In the area of strengthening health systems, the capacity
of civil society to be active players in the health system has increased significantly and the
capacity of the private sector has been increased through social marketing and social franchising
approaches. In some countries this capacity building has occurred in the context of fragile health
systems, where alternative service delivery mechanisms such as civil society and the private
sector have been needed. Public health systems have acknowledged the benefits of this greater
involvement by civil society and the private sector.  
Other examples of where GHI approaches are evident in PSI’s work are:  
• An integrated approach to public health: PSI’s broader public health work and integration of
HIV with reproductive health and family planning and HIV/TB work.  
• Outcomes focused: PSI’s strong focus on using strategic information to guide programs to
achieve outcomes, and the ongoing monitoring of results.  
• Leverage: broadening of PSI’s funding base beyond USG.  
2.2.4 Replication and sustainability
PSI’s large scale social marketing of condoms and lubricant has significantly grown the size of the
market by developing a demand for these products. This has been accompanied with the
development of buying habits for condoms so access to prevention is not solely reliant on free
distribution. A possible concern in terms of sustainability is PSI’s dominance of the condom
market in Burma and Lao. However, PSI recognizes the need to encourage new private sector
entrants into the condom market, (which is occurring in Lao), to ensure long term sustainability,
whilst ensuring that affordable condoms are available to the poor and most vulnerable.  
Public health officials in the four countries are increasingly seeing the value of community led
approaches to HIV prevention. However, the broader political environments in three of the four
countries are not encouraging for the development of civil society. Considerable work remains to
be done in documenting and advocating for this approach. The capacity building of peers has
developed knowledge and skills in prevention programming, although there has been a lesser
8
emphasis on strengthening organizational development given most peer led programs are
operating under the auspice of PSI.  
Although there has been significant capacity building of local project staff by PSI in strategic
information, there has not been a parallel process of developing the capacity of other partners
and governments.  
PSI’s social franchising of health services has good sustainability potential as it has been
accompanied by ongoing capacity building of pharmacies, medical practitioners and community
health workers.  
Replication of PSI’s programming has been occurring in a number of ways. As additional funds
are mobilized from other donors, this has allowed PSI’s existing programs to be replicated in new
sites. The elements of USAID’s Comprehensive Prevention Package model, being implemented
by PSI, has also had a significant influence on the prevention programming of other donors and
in the programming approach reflected in Global Fund proposals. PSI has also been active in
promoting replication in national and regional forums. More broadly, the HIV and AIDS
National Strategic Plans of all four countries now prioritize MARPs and the prevention
approaches in these strategies have been strongly influenced by the CPP. This type of replication
significantly strengthens sustainability.  
9
3. Burma 
3.1 HIV prevalence in Burma 
Adult HIV prevalence in Burma in 2009 was estimated to be 0.6%. Sentinel surveillance among
pregnant women (32 sites) in 2008 found an HIV prevalence rate of 1.3%. The epidemic is
primarily concentrated in MARPs: MSM 29% (2 sites); FSW 18% (6 sites); IDU 38% (6 sites). HIV
prevalence among male STI patients (a proxy for clients of sex workers) was 5% (33 sites). HIV
prevalence among new TB patients was 11% (10 sites). The 2008 sentinel surveillance survey
found prevalence of syphilis was highest among MSM (14%), followed by FSW (6%), new TB
patients ( 5%), and male STI patients (4%).1
3.2 Overview of PSI/Burma program 
PSI/Burma works in six public health areas: HIV/STIs, TB, malaria, reproductive health, diarrheal
diseases and pneumonia. USAID/RDMA funding is supporting PSI’s work in HIV and TB. For FY
10 USAID funding makes up 31% of PSI’s HIV budget and 47% of PSI’s TB budget. USAID
funding supports the Targeted Outreach Program (TOP) for MSM and FSW services and STI
technical assistance and quality assurance for the Sun Quality Health network doctors. Other
donors currently supporting PSI’s public health programs include United Nations (UN) agencies,
the Three Diseases Fund, DANIDA, and the Bill and Melinda Gates Foundation. From 2011, PSI
will receive Global Fund Round 9 funds.  
The implementation mechanisms used by PSI/Burma to implement its public health programs are:  
• The Targeted Outreach Program for MSM and FSW
• Two QC VCT centers in Rangoon and Mandalay for the general population, with a focus on
clients of FSW. These centers also conduct sputum testing for TB
• DOTS TB program implemented though the Sun Quality Health and Sun Primary Health
networks
• Sun Quality Health (SQH) network, which is a branded franchise network of 1006 private
doctors throughout Burma working in all six of PSI public health areas, targeting low income
people, with extensive technical support from PSI
• Sun Primary Health, which is a network of 776 community health workers in 33 rural
townships delivering health communication messages, basic services, health products and
making referrals
• Malaria prevention, diagnosis and treatment program
• Mass media and targeted communications across the six public health areas
3.3 Prevention 
3.3.1 Outline of the Burma prevention program
PSI’s HIV prevention work for MSM and FSW is provided by TOP, which was established in 2004.
The core elements of the program are BCC interventions through peer outreach and DiC activities,
condom social marketing, VCT and STI clinical services in DiCs, including social marketing of
branded STI treatment kits, and support for PLHA, plus referral to external HIV care and
treatment services. In Rangoon and Mandalay, PSI also operates QC VCT centers which are
                                                      1
   WHO and National AIDS Program, Report of the HIV Sentinel Sero–Surveillance Survey 2008. 2009.
10
targeted to the general population, with an emphasis on clients of sex workers. The QC centers
also conduct sputum tests for TB. The QC centers are not funded by USAID.  
3.3.2 Key achievements
Increased access to prevention interventions for MARPs
TOP’s geographic reach
The core elements of the TOP model described in 3.3.1 have been progressively scaled–up since
2004 and these interventions are now provided in 15 townships in Burma. In 2010, TOP will
expand to an additional 5 townships, and in 2011 to a further 9 townships, giving the program
coverage in 29 locations. Geographic scale–up has been prioritized, by firstly opening programs
in larger cities and then expanding to smaller cities/townships. PSI estimates that operations in 29
townships will give it potential reach to 85% of MSM and FSW in Burma. At this level of
geographic scale, this would be largest single HIV prevention program for MSM and FSW in Asia.
(See Annex 3 for a map of the current locations of the TOP program.)
TOP activity data
The following section provides an outline of TOP activity data which demonstrates significantly
increased access to prevention interventions. More detailed data is contained in tables in Annex 4.  
TOP outreach activity levels: MSM 2
 
Outreach is the most important element of TOP as it has the largest reach of all project
components. A client unique identification code (UIC) is not used for outreach contacts, but a
record of new individual outreach contacts is maintained. (A UIC is used for DiC visits.). Key
data for MSM outreach activities are:
• New outreach contacts with individual MSM from 2007–2009 totaled 132,378 which made up
36% of total MSM outreach contacts.
• Total outreach contacts with MSM (not individuals) increased by 47% between 2007–2009 and
totaled 372,467 contacts for the three years.  
• A total of 147,435 outreach contacts were made with MSM in 2009, which is an average 189
contacts per week, per TOP site. (See Table 6 in Annex 4 for more details.)
TOP outreach activity levels: FSW 
Key data for FSW outreach activities are:
• New outreach contacts with individual FSW from 2007–2009 totaled 97,188, which made up
31% of total FSW outreach contacts.  
• Total outreach contacts with FSW (not individuals) increased by 46% between 2007–2009 and
totaled 317,070 contacts for the three years.
• A total of 130,306 outreach contacts were made with FSW in 2009, which is an average 167
contacts per week, per TOP site. (See Table 7 in Annex 4 for more details.)
TOP DiC activity levels: MSM
From 2004–2009 a total of 38,083 individual MSM visited a DiC on at least one occasion. In 2009, a
total of 19,621 individual MSM visited a DiC on an average of 5 occasions. This means that 18,642
                                                      2 This section provides activity data for the calendar years 2007–2009. USAID funding of PSI’s
activities under the existing contract extension commenced in October 2007. Accordingly, the 2007
data can primarily be regarded as baseline data for this contract.
11
MSM who visited a DiC at least once between 2004–2008 did not return in 2009, a non–return rate
of 49%. It is likely that a number of these MSM were contacted through outreach activities,
although there is no data to indicate the extent to which this was the case. Other key data relating
to DiC utilization are:  
• Over the period 2007‐2009 there were a total of 215,289 visits by MSM to DiCs (not
individuals).  
• Total DiC visits by individual MSM increased by 92% between 2007–2009.  
• The total of 98,137 DiC visits by MSM in 2009, (not individuals), approximates an average of
27.3 visits per day, per DiC, across the 15 sites.3 (See Table 8 in Annex 4 for more details.)
TOP DiC activity levels: FSW
From 2004–2009 a total of 30,721 individual FSW visited a DiC on at least one occasion. In 2009, a
total of 15,936 individual FSW visited a DiC on an average of 5.1 occasions. This means that
14,785 FSW who visited a DiC at least once between 2004–2008 did not return in 2009, a non–
return rate of 48%. It is likely that a number of these FSW were contacted through outreach
activities, although there is no data to indicate the extent to which this was the case. Other key
data relating to DiC utilization are:  
• Over the period 2007‐2009 there were a total of 178,787 visits by FSW to DiCs (not
individuals).  
• Total DiC visits by individual FSW increased by 87% between 2007–2009.  
• The total of 81,414 DiC visits by FSW (not individuals) in 2009 approximates an average of
22.6 visits per day, per DiC, across the 15 sites. (See Table 9 in Annex 4 for more details.)  
TOP outreach and DiC coverage
The large increases in outreach contacts and DiC visits by MSM and FSW from 2007–2009
represent a significant achievement in increasing access to prevention interventions. This is one of
the four objectives or intermediate results of USAID’s agreement with PSI. The increases in both
outreach contacts and DiC visits is driven by expansion of TOP to new sites and increased
coverage in existing sites. PSI regards outreach as the ‘backbone’ of the TOP program as it is able
to reach more MSM and FSW, compared to DiC visits.  
Trends in outreach contacts and DiC visits from year to year have generally shown significant
increases, however, the extent of increase for some years has been effected by external factors
such as Cyclone Nargis, political unrest and the temporary government closure of the Mandalay
DiC.  
Because unique identifier codes are only used for DiC visits it is not possible to calculate the total
number of individual MSM and FSW reached by TOP. However, incomplete coverage estimates
can be determined for 2007–2009 using the following data:
• The number of new outreach contacts (recognizing there may be some double–counting); and
• Deriving a percentage of MSM who came to DiCs without any previous outreach contact with
TOP. PSI’s internal monitoring system indicates that 90% of MSM and FSW coming to DiCs
say they learnt about the DiC from peer outreach workers and the remaining 10% have had
no previous contact with the program. Accordingly, 10% of new individual DiC members can
be regarded as new contacts.  
                                                      3
 Calculated on the basis of DiCs being open 240 days a year. Attendance at DiC varies significantly
by locality and the average would be depressed because 3 new DiCs would not have been open 240
days.
12
Using this approach, from 2007–2009 PSI reached a minimum of 134,584 individual MSM. The
National Strategic Plan for HIV and AIDS (NSP) estimates 240,000 sexually active MSM, based on
an assumption that 2% of males aged 15–49 years have sex with other males in the previous 12
months. PSI regards this estimate as conservative. Coverage of 134,584 individual MSM for 2007–
2009 represents a national coverage rate of 56%. By regional standards, this is a high coverage
rate.  
Using the same approach, from 2007–2009 PSI reached a minimum of 99,444 individual FSW. The
NSP estimates there are 60,000 FSW in the country at any given time. This too is seen as a
conservative estimate. The population size estimate for FSW may be a significant underestimate
as each year there are many new sex workers and many who exit this type of work. Using the
NSP estimate, PSI reached 165% of individual FSW between 2007–2009.  
TOP is clearly reaching a higher proportion of the estimated number of FSW compared to MSM.
This may be because FSW are less hidden than MSM, as many work in entertainment
establishments where PSI has good access.  
The Myanmar NSP Progress Report for 2008 estimated that PSI reached 78% of all MSM reached
by HIV programs in the country that year. PSI’s share of total national coverage for FSW in 2008
was 52%.
STI clinical services: MSM
Between 2007 and 2009, the number of STI consultations and/or occasions of treatment for MSM
at TOP DiC clinics increased from 3,972 to 8,749, or by 120%. In 2009, only 45% of individual
MSM who attended a DiC also had an STI consultation and/or treatment. In 2007, 39% of DiC
attendees had an STI consultation or treatment. A bigger increase might have been expected
given the increased availability of STI clinics at DiCs over this period. (See Table 10 in Annex 4
for more details.)  
STI clinical services: FSW
Between 2007 and 2009, the number of STI consultations and/or occasions of treatment for FSW at
TOP DiC clinics increased from 4,948 to 9,153, or by 85%. In 2009, 57% of individual FSW who
attended a DiC also had an STI consultation and/or treatment. The percentage of FSW attending
STI clinics did not vary significantly from earlier years. Growth in the percentage of FSW
utilizing clinics might have been expected given the increased availability of STI clinics at DiCs
over this period. Compared to MSM, the STI health seeking behavior of FSW is better. (See Table
11 in Annex 4 for more details.)  
VCT services: MSM
The number of MSM having VCT at TOP DiCs increased from 1,520 in 2007 to 2,514 in 2009, or by
65%. The number of MSM who tested positive at TOP DiCs ranged by year from 11–17%. The
percentage of individual MSM attending DiCs who also had VCT was low, ranging from 15% in
2007 to 13% in 2009. (See Table 12 in Annex 4 for more details.)
VCT services: FSW
The number of FSW having VCT at TOP DiCs increased from 2,022 in 2007 to 2,664 in 2009, or by
32%. The number of FSW who tested positive at TOP DiCs ranged by year from 17–19%. The
13
percentage of individual FSW attending DiCs who also had VCT was low, ranging from 24% in
2007 to 17% in 2009. (See Table 13 in Annex 4 for more details.)
TOP STI and VCT coverage
VCT services in TOP DiCs have only been available since December 2009, with the exceptions of
Rangoon and Mandalay where these services commenced in 2005. STI services at DiCs have been
rolled out progressively to DiCs, mainly in 2008 and 2009. The more extensive provision of STI
services over a longer period of time may explain the higher growth rate for MSM attending for
STI services compared to VCT. The recent expansion of both VCT and STI services is likely to
result in an increase in service utilization.  
2009 STI and VCT coverage rates by PSI for MSM and FSW in relation to the estimated total
population sizes for Burma were low, but higher for FSW compared to MSM:  
• MSM use of TOP STI services  =   3.6% coverage
• FSW use of TOP STI services  =   15% coverage
• MSM use of TOP VCT services  =   1% coverage
• FSW use of TOP VCT service  =   4.4% coverage
It is possible that MSM and FSW who use PSI DiCs are having HIV tests in VCT services
provided by other service providers. There is, however, no data on this and given most other
VCT clinics are government clinics, the number of MSM testing at other centers may be small.
However, it is important to note that once a MARP is HIV positive and knows their status, they
no longer will need HIV testing. Given that HIV prevalence in the country is mature and
particularly high in these populations, there may be a significant proportion of HIV positive
MARPs who already know their status. However, given the low rates of HIV testing among MSM
and FSW as indicated by the PSI data, this is unlikely to the be case.  
Technical assistance and quality assurance for STI and VCT services
PSI has clinical guidelines and standard operating procedures in place for its STI and VCT clinical
services. FHI’s regional Technical Advisor for Sexual and Reproductive Health provided a four
day training course on STI management, with a particular focus on MSM and FSW, to PSI and
Alliance medical staff in 2009 and has done similar trainings in previous years.  
PSI/Burma employs 78 medical practitioners in its headquarters who are responsible for
providing technical assistance and quality assurance across PSI’s six public health/disease areas,
including STIs, to the Sun Quality Health network doctors, and to doctors working in the TOP
clinics. Younger PSI doctors conduct monthly visits to all Sun Quality doctors and TOP clinics,
monitoring the work of doctors against PSI’s protocols. If problems with clinical practice are
found, a more senior doctor from the ‘champions’ PSI has for each public health area is called to
provide more specialized guidance. For STIs, these champion doctors have been sent to Thailand
for specialized short course training. Sun Quality and TOP doctors participate in quarterly review
meetings for clinical and practice updates. Refresher training is also conducted. Mystery clients
were used to monitor quality. This is being replaced with mystery observers. In smaller
townships, Sun Quality doctors are contracted to work in TOP clinics. Sun Quality doctors are
usually the more senior doctors in town.  
TOP condom and lubricant sales and distribution to MSM and FSW
From 2007–2009 sales of female condoms to MSM by TOP increased by 546% from a low base. In
2009, female condom sales to MSM were 15% greater than sales to FSW. Sales of female condoms
14
to female sex workers declined by 25% between 2007–2009 but were still high compared to other
countries in the region.4 See Table 1, below.  
Table 1 : Female condom sales by TOP to MSM and FSW: 2007–2009
Year Female condoms sold to
MSM
% increase on
previous year
Female condoms sold
to FSW
% decrease on
previous year
2007 17,681 – 133,040 –
2008 39,727 125 127,870 – 4
2009 114,278 188 99,751 – 22
Total 171,686 360,661
Source: PSI/Burma
Sales of male condoms and lubricant to MSM and FSW by TOP is not disaggregated. Between
2007–2009 sales of male condoms to MSM and FSW increased by 101%. The growth in sales from
2008 to 2009 was significantly less compared to the previous year. The increasing popularity of
female condoms among MSM in 2009 may have limited the growth of male condoms sales to
MSM. PSI markets small tubes of water based lubricant in addition to smaller single–use sachets.
From 2007–2009 sales of lubricant tubes increased by 61% and sales of sachets increased by
6,061% from a very low base. See Table 2, below.  
Table 2: Male condom sales by TOP to MSM and FSW: 2007–2009
Year
Male condom
sales to MSM
and FSW
% increase
on previous
year
Lubricant tube
sales to MSM
and FSW*
% increase
on previous
year
Lubricant sachet
sales to MSM
and FSW*
% increase
on previous
year
2007 235,485 – 27,868 – 1,240 –
2008 410,620 74 20,878 – 25 4,800 287
2009 472,840 15 44,729 114 76,400 1,491
Total 1,118,945 93,475 82,440
* Gel tubes contain 20 cc of water based lubricant. Gel sachets contain 5 cc of water based lubricant. Source:
PSI/Burma
In 2008 TOP reached a minimum of 54,067 individual MSM and 40,935 FSW.5 In 2009, TOP
sold/distributed an average of:  
• 2.1 female condoms to each MSM reached
• 2.4 female condoms to each FSW reached
• 5 male condoms to each MSM/FSW reached (disaggregated data not available)
In addition, 1.063 million Aphaw Gel condoms and sachets of lubricant were sold through PSI’s
broader condom social marketing program (see below). Assuming the market for jointly
packaged condoms and lubricant is MSM and FSW, this equates to an average of 11 sales per
MSM/FSW reached by TOP. Alternatively, using combined population estimate data for MSM
                                                      4
 PSI markets female condoms under two brands: Feel for Men and Feel for Women. In 2008 stock––
outs of Feel for Men resulted in Feel for Women condoms being sold to MSM. In 2009 there were no
stock–outs of Feel for Men which led to a reduction in sales for Feel for Women sales in 2009
compared to 2008. 5 These figures are made up of all MSM and FSW reached by outreach for the first time, plus 10% of
new DiC members and DiC members who registered in previous years and used in the DiC in 2009.
The numbers of MSM and FSW reached are underestimates as repeat outreach contacts with MSM
reached in previous years are not included (no data available). Accordingly the average sales of
condoms per MSM/FSW reached are an overestimate.
15
and FSW (i.e. 300,000 people) it equates to 3.5 condoms sales per MSM/FSW. However, as other
brands of male condoms are also purchased by MSM and FSW, these are underestimates of
condom sales.  
PSI’s broader condom social marketing program
In addition to the sales and distribution of condoms and lubricant by TOP, PSI’s broader national
condom social marketing (CSM) program, through 3,772 traditional and 4,380 non–traditional
outlets, sells a range of male condom brands to a broad range of population groups, including
MSM and FSW. It is, however, not possible to collect data on sales to different populations
groups. From 2007–2009, sales of male condoms increased by 32% to a total of 26.6 million
condoms (Table 3). PSI estimates that it has approximately 80% of Burma’s condom market. Four
percent of total male condom sales in 2009 were the ‘Aphaw Gel’ brand which jointly packages
condoms and water–based lubricant. This brand would usually be purchased by MSM and FSW.
As tubes of lubricant are also marketed by PSI, MSM and FSW may purchase other brands of
condoms that are not packaged with lubricant and use the tubes for lubricant. From 2007–2009,
sales of lubricant tubes increased by 113% and sales of lubricant sachets (jointly packaged with
condoms) increased by 33%. Approximately 8% of the total 26.6 million condom ‘sales’ in 2009
were for promotion and free distribution. Total income from sales of condoms in 2009 was
$0.387m. One–third of this income was attributable to condoms purchased with USAID funds.
Income is generally used for purchasing further commodities, packaging and similar purposes.  
Table 3: Male condom sales by PSI’s broader condom social marketing (non–TOP): 2007–2009
Year
Male
condom
sales
% increase on
previous year
Lubricant
tube sales
% increase on
previous year
Lubricant
sachet sales
% increase on
previous year
2007 20,223,947 – 24,461 – 801,597 –
2008 23,350,288 15 22,921 – 6 1,123,263 40
2009 26,616,218 14 52,143 127 1,063,600 – 5
Total 70,190,453 99,525 2,988,460
Source: PSI/Burma
Behavior change
Behavioral data from TRaC surveys with female sex workers and their clients mostly showed
improved safer sexual practices. For female sex workers, consistent condom use with commercial
partners in the past week improved from 67% in 2003 to 87% in 2008. Over the same period,
national HIV surveillance showed a reduction in HIV prevalence among FSW from 31% to 18%.
Consistent condom use with regular partners in the past month was first measured in 2008 and
was 68%. For clients of sex workers consistent condom use with sex workers in the past month
increased from 58% in 2003 to 87% in 2008. However, consistent condom use by clients of female
sex workers with regular partners declined from 23% in 2003 to 13% in 2008.
For MSM the baseline TRaC survey was conducted in 2008, with a further survey to be conducted
in 2010. The 2008 survey found that 62% of MSM consistently used condoms with casual partners
in the past week and that 51% consistently used condoms with regular partners in the past month.  
PSI’s TRaC surveys in Burma have found that consistent condom use by MSM, FSW and clients
of FSW increases when they are exposed to additional elements of the comprehensive package of
services, (formerly called the minimum package of services) and multiple outreach contacts (see
Figure 1 below).  
16
Figure 1: Percentage of target population’s consistent condom use by exposure, 2008
Source: PSI/Burma
Increased access to care and support for PLHA
Since 2007, TOP has provided increased care and support to MSM and FSW PLHA through its
DiCs. Specific initiatives have been:  
• TOP has trained volunteer peer ‘buddies’ to provide care and support to PLHA.
• The FHI self care booklet has been translated and distributed to PLHA.  
• All DiCs are now open on Saturdays for the exclusive use of PLHA. This is called the
Saturday Club and includes peer psycho–social support and small scale income generating
projects.  
• A national network of positive MSM and FSW has been established under the auspice of TOP.  
All MSM and FSW who test positive for HIV are referred to external care and treatment services.
Access to HIV care and treatment services in Burma varies significantly by geographic area, but is
generally limited. In particular, access to ART is very limited, with a significant gap between
need and supply. Access to ART will improve slowly, starting in 2011 with the Global Fund
round 9 grant, but there will still be a large gap between ART need and the available treatment
places.  
In November 2008, PSI/Burma launched an ART pilot project in Rangoon at the QC Center, TOP
DiC, and eight SQH clinics for 50 HIV positive clients who met clinical eligibility criteria.
Counselors at the QC Centers provide adherence counseling to all ART clients because SQH
providers have less time for counseling. This is an innovative new pilot and should be watched
carefully as this type of service could be incorporated into PSI/Burma’s existing programs. This
would provide a direct link in the continuum of prevention to care, support and treatment. And
given that the ART coverage is still low, reaching only one fifth of the people in need, additional
17
and alternative investments in ART provision remains an urgent need6. If the pilot were to be
expanded and incorporated into PSI’s existing program it would have significant financial and
human resource implications for the clinics at DiCs. This would require either additional
resources or some diversion of prevention program funding.  
Strengthening the enabling environment
Although TOP has no identifiable separate program component for strengthening the enabling
environment, its activities have contributed to this indirectly in a number of ways:  
• The scale–up of services to 15 sites has resulted in the needs and challenges of MSM and FSW
becoming more visible to public health officials and service providers at both the township
level and to the National AIDS Program. MSM were recognized as a MARP for the first time
in the National Strategic Plan, 2006–2010.  
• DiCs for MSM and FSW provide both social recognition and safe spaces and this has helped
to increase social confidence and reduce self–stigma.  
• DiCs have provided safe spaces for being open about HIV status. This has reduced stigma
faced by PLHA from MSM and FSW peers.
• The provision of on–site VCT and STI services has provided access to non–discriminatory,
MARP focused services.  
• Capacity building of peers has provided a sense of self–confidence which has reduced
internalized self–stigma and facilitated community mobilization.  
• Facilitated referrals to care, support and treatment services have increased MSM and FSW
access to care, treatment and support by overcoming discriminatory health service practices.  
3.3.3 Strengths and facilitating factors
Significantly increased access to prevention interventions by MSM and FSW has been achieved
by TOP having a strong orientation towards scaling–up. This has resulted in a ‘boutique’ type
project reaching significant scale. Scale–up has had a dual focus of expanding to new townships
and reaching an increasing number of MSM and FSW in existing sites.  
While TOP is a PSI program, a community mobilization approach has been taken. All aspects of
program development and implementation have been conducted by peer MSM and FSW.
Strengthening the capacity of peers has been a core feature of TOP. TOP has held three annual
National Network meetings, one for MSM and one for FSW, which brings program staff and
peers together for review and capacity building. Achieving a community mobilization approach
in the context of Burma, where civil society organization is not permitted, is a very significant
achievement. PSI, as a large INGO, has been able to auspice and provide the protection for this to
occur on a national scale.  
While the TOP has been implementing the core elements of USAID/RDMA’s Comprehensive
Prevention Package, testing of innovation has been a strong feature of program development:  
Separate DiCs for MSM and FSW in the one building in each of the 15 sites
In smaller DiCs the one clinic provides VCT and STI services to MSM and FSW, resulting in cost
savings. Combined DiCs also result in cost savings in rental, management and other overheads.
This approach also allows for cross–fertilization between program staff working with MSM and
FSW and some combined program activities for MSM and FSW such as the Saturday Clubs for
                                                      6 National Strategic Plan for HIV and AIDS in Myanmar, National AIDS Program; Progress Report
2008
18
PLHA. Combining DiCs for multiple MARPs is not commonly seen in other countries. In Burma
there appears to be a high degree of acceptance of this approach by MSM and FSW.  
Broad targeting of all MSM and FSW
While a segmented approach to HIV prevention interventions is often used in other countries,
with different community–based organizations (CBOs) targeting different sub–populations of
MSM and FSW, TOP targets all MSM and FSW. Measuring the extent to which TOP reaches a
broad diversity of MSM and FSW is hard to gauge in the absence of data. However, DiCs appear
to be attracting both feminized and non–feminized MSM, but more feminized MSM compared to
non–feminized MSM, and also different types of FSW (e.g. entertainment establishments and
street based). Outreach provides a basis for reaching a broader cross–section of MSM and FSW.
Broad targeting, which results in different groups sharing the one DiC space, appears to be
working well. This approach also results in cost savings.  
Condom and lubricant social marketing
Program monitoring data indicate that around 80% of male condoms marketed through TOP are
sold at subsidized prices to MSM and FSW, with only 20% being provided for free or used for
promotional purposes. Female condoms are generally only sold due to a higher unit cost,
although they are subsidized. The emphasis on selling condoms encourages buying habits among
MSM and FSW for the purpose of sustainability. Comparable HIV prevention programs for MSM
and FSW in Asia generally place a greater emphasis on free distribution, and many have only
limited supplies for free distribution.  
PSI/Burma increased condom coverage in traditional outlets by sub‐contracting condom
distribution to a private sector company with a well established national distribution network.
This has allowed PSI/Burma sales and outreach teams to concentrate on condom distribution to
non–traditional outlets.  
Promotion of the female condom
An innovative aspect of PSI’s programming is promotion of female condoms for male–to–male
sex. This is accompanied by small group education sessions for MSM on how to safely use the
female condom. Sales figures for female condoms to MSM show a high degree of acceptability of
this method of protection. However the active promotion of female condoms to MSM increases
program costs, even with a social marketing approach. This is because female condoms are
considerably more expensive than male condoms and they are heavily subsidized. There is also
strong promotion of the female condoms to FSW, particularly compared to other countries.  
Promotion of lubricant
Another innovation is the development and marketing of branded tubes of water–based lubricant
to MSM and FSW, in addition to selling sachets of lubricant, jointly packaged with condoms. In
most other countries lubricant is only socially marketed in sachets. Sales figures indicate that
these tubes, which are small enough to conveniently carry, are popular with MSM and FSW.
Beyond the increase in condom use which occurs when lubricant is available, lubricant use alone
is a harm reduction method, as it prevents anal and vaginal tears and fissures which increase HIV
transmission.  
On–site VCT and STI services
All DiCs now have on–site VCT and STI clinical services for MSM and FSW. This promotes ready
access rather than relying on referrals to external services and clients can be confident of stigma–
19
free services. TOP employs peer VCT counselors who have been trained and accredited by the
Ministry of Health. This peer driven approach is intended to increase HIV testing rates by
providing counselors who understand MARP lifestyles and needs. PSI is only one of two NGOs
in Burma which is allowed to provide VCT. Rapid testing is available in Rangoon and Mandalay.  
Integrated approach to TB
TB screening, treatment and referral has been integrated into the work of the TOP clinics,
including provision of cotrimoxazole prophylactic therapy for TB/HIV co–infected clients. All TB
cases are counseled for HIV testing and all HIV positive cases are screened for TB.  
Structured behavior change messages
All new outreach contacts receive a structured 45 minutes behavior change communication
session from a peer educator, the content of which is informed by PSI’s research on the
determinants of behavior. Repeat contacts reinforce different messages and answer peer
questions.  
Addressing the needs of PLHA
A defining feature of TOP is its work with MSM and FSW PLHA. This stands in contrast to HIV
prevention programs in other countries in the region where programs often have an implicit
orientation towards HIV negative peers. There is evidence of PLHA in TOP DiCs being open
about their HIV status. This may be related to the high HIV prevalence among MSM and FSW (at
least in some sites), but also appears to be related to a significant number of peer staff being open
about their HIV status and a decision by TOP to facilitate an open and supportive environment
for PLHA. A range of programmatic initiatives (e.g. the Saturday Clubs) have also fostered this
openness. Additionally, the PSI national warehouse is staffed entirely by PLHA.  
All of these innovations have helped develop a richer and more robust model. While there has
been some dissemination at regional workshops on some aspects of TOP’s innovation, formal
documentation and dissemination would help to inform MSM and FSW programs in other
countries of the benefits of these innovations.  
3.3.4 Challenges and barriers
The following challenge and barriers were identified:  
Reach into hard reach populations
Although data on increased access to HIV prevention interventions demonstrates an impressive
depth of penetration, PSI recognizes that there is a need to further increase coverage in existing
sites by extending its reach, particularly for MSM. As is common with HIV prevention programs
for MSM in the region, reach is higher for working class MSM, with lesser coverage for middle
class and upper class MSM. PSI has explored different methods of accessing these MSM and they
do appear for certain large‐scale social events.  
Consistent condom use with regular partners
As with other countries in the region, behavioral monitoring has indicated that consistent
condom use by MSM and FSW with regular partners is significantly less than for casual partners.
Similarly, consistent condom use by the clients of sex workers with their regular partners is less
than with sex workers. TOP has identified this as a focus area for its work in 2010.  
20
Condom social marketing
PSI’s orientation towards condom social marketing and limited distribution of free condoms and
lubricant is not shared by all other INGOs operating in Burma. As these INGOs are also working
(on a lesser scale) with MSM and FSW, their free distribution of condoms and lubricant could
undermine the buying habits that PSI is attempting to establish. PSI could undertake advocacy
work with these partners on the benefits of social marketing.  
Lubricant supplies
In previous years there have been supply shortages for the small tubes of lubricant. This product
is clearly popular with MSM and FSW and efforts should be made to increase supplies.  
STI check–up and VCT utilization rates are low
The recent expansion of STI and VCT clinical services has increased access. This needs to be
accompanied by generating demand for these services. Rapid HIV testing cannot be provided in
most DiCs due to unreliable electricity supply which means that cold chain cannot be maintained
for test kits. In these instances, blood is taken and sent to government laboratories. The main
disadvantage is the need to ensure that clients return for their test results.  
Opening hours of DiCs
All 15 DiCs are open from 9–5 Monday to Friday. While this time appears suitable for FSW who
mainly work at night, opening in the early evening may be suitable for MSM, especially those
who are working. This may help broaden reach into more middle class MSM.  
STI and VCT quality assurance
It was not possible to assess the adequacy of PSI’s STI and VCT quality assurance system.
Following his 2009 technical inputs, FHI’s regional Technical Advisor for Sexual and
Reproductive Health recommended that both PSI and the Alliance strengthen their oversight of
clinical service delivery in Burma.  
Care, support and treatment
High HIV prevalence rates among MSM and FSW and the low availability of care and treatment
services in the country has resulted in PSI placing a greater emphasis on care and support for
PLHA. When PLHA are referred to care, support and treatment programs, limited availability of
ART in Burma means that the services have been limited to clinical monitoring, care and
treatment of opportunistic infections. PSI is looking to strengthen its capacity to support MSM
and FSW PLHA. One option would be to establish a care and treatment support function/unit
within TOP DiCs to facilitate referrals to care, support and treatment services and to advocate on
behalf of PLHA experiencing access problems, to provide psycho–social support, adherence
support and possibly case management or joint case management with other services. However,
under this model the DiCs would not directly provide clinical services beyond the current range
of services.  
3.3.5 Replication and sustainability
PSI has been able to successfully leverage significant amounts of non–USAID funding to support
its HIV work. Additional funding from other donors has allowed scale‐up to new townships and
replication of the model on a broader scale. By the end of 2011 TOP will be operating on a
national scale. This is also the product of having one implementing organization (i.e. PSI through
its TOP program). National level scale up would have been difficult if funding was for range of
different NGOs/CBOs.  
21
PSI/Burma estimates that it has 80% of the national condom market. This is a significant
achievement which has made quality condoms at an affordable price accessible to the people of
Burma. Expansion of condom social marketing has been accompanied by significant capacity
building of the private sector and this will be reinforced with the contracting out of PSI’s national
condom distribution. PSI’s dominance of the condom market may have negative implications for
long term sustainability. It would be highly desirable if there were more marketers of condoms.
While the subsidization of condoms can make it difficult for others to compete with PSI,
increasing the prices of PSI condoms could result in a significant reduction in sales to the poor.
Addressing this issue is complex. One approach is to keep the price of at least one socially
marketed brand low, while modestly increasing the cost of other socially marketed brands. This
approach recognizes that there are a range of market segments with different price sensitivities.
Also, as condom use and buying habits become more established there may be less overall price
sensitivity in the market. As a general principle condom social marketing should be done in such
a way that it does not prevent or discourage other entrants to the market, whilst at the same time
ensuring that condoms are available at a price where those at risk can afford them. At a minimum
PSI is well placed to provide technical assistance to potential private sector marketers of condoms
on a range of marketing and logistical issues. PSI is aware of these issues and proactively
developing a strategy to encourage a diversity of condom suppliers in the market.
Capacity building has been a strong feature of PSI’s program. This has included significant
capacity building of the private sector in the context of a fragile public sector health sector. The
Sun Quality Network has proved to be an effective way of delivering public health services
through general practitioners on a national scale. The extensive capacity building of MSM and
FSW by TOP has provided a de–facto CBO style organization with capacity for self management.
Prior to the establishment of TOP in 2004, there were no MSM friendly and clinically appropriate
STI services for MSM and FSW in Burma. TOP has concentrated its efforts in developing internal
capacity to provide STI clinics in DiCs. Unlike other countries, there has been no capacity
building of government STI clinics. The capacity of Sun Quality doctors to provide STI services
has been developed although this has not included clinical skills on STIs in MSM. PSI is planning
to develop the capacity of Sun Quality doctors to provide MARP appropriate and friendly STI
services. This should be accorded a high priority in the interests of sustainability.  
3.4 Strategic Information 
3.4.1 Outline of key strategic information activities
Strategic information refers to the kind of evidence–based information needed to inform policy
and planning decisions. Strategic information on HIV comes from four main sources:  
• Surveillance
• Monitoring and evaluation of ongoing programs
• Health information systems
• Research
PSI/Burma’s strategic information activities have been in the following four areas:  
1. Project MIS System monitors program service delivery and allows for reporting on
indicators at the output level, including intermediate results.
22
2. TRaC Surveys collect the data used to track evolving trends in logical framework indicators
at the purpose, output, and activity levels within the target population. TRaC surveys
provide detailed data important to social marketing segmentation, monitoring, and
evaluation on a timely basis, enabling fine tuning of project interventions every year during
implementation.  
3. Project MAP service delivery surveys monitor and evaluate the relationship between product
and service availability and quality and behavior among target populations.
4. Qualitative Research is used for concept development, pre–testing intervention materials,
item generation (for TRaC surveys) and, if necessary, exploring questions raised in
segmentation. The specific strategy used depends on the topic and can result in the use of key
informant studies, focus groups, in depth interviews, or peer ethnographic research.
The Strategic Information Department has a total of 23 employees. The staff are mostly country
nationals who conduct the routine M&E and research activities. This sub‐section reviews the
strategic information activities contained in the PSI/Burma annual workplans for the period 2007‐
2010. An outline of these activities is Annex 5.  
3.4.2 Key achievements
Increased access to strategic information
PSI/Burma programs are evidence based and data driven
Routine program monitoring and evaluation
PSI/Burma continuously analyzes routine program data and using it for quality project design
and implementation. Data flow from routine program M&E is logical to ensure a good
continuous feedback loop of information to all levels of the program.
Project MIS System and data flow for the TOP Centers
Routine program data are collected through a Project MIS system. During outreach and at the
DiC service delivery sites, client participation data are collected through paper–based systems by
peer outreach workers and DiC staff. Additionally, clinical service data are also collected through
paper–based systems by staff doctors and laboratory technicians. The data are then aggregated
and cleaned on a weekly basis and entered into an excel spreadsheet by a person with MIS skills
at each Top DiC. These data are reviewed on a weekly basis by TOP’s National Director and the
TOP Technical Support Unit (TSU). The TOP management staff have weekly meetings where the
week’s data are reviewed and issues are discussed. If any improvements need to be made after
looking at the data, then the TSU works closely with the TOP DiC staff and peer outreach
workers to implement changes.  
Additionally, the TOP Center routine program data are aggregated on a monthly basis by the
MIS specialist and the data are displayed on whiteboards within the DiC for clients and peer staff
to see monthly performance. These monthly data reports are also sent to the PSI/Burma HQ office
where the Strategic Information and Research Department manages the monthly data from all
TOP Centers in a database. The TOP National Director also receives a copy of the aggregated
monthly data from all TOP Centers and shares that with DiC staff.  
The PSI/Burma MIS Team reviews and cleans aggregated data and does follow–up data quality
checks with individual TOP Centers if data do not look correct. There are also checks that have
23
been employed throughout the system to ensure data quality and program quality. PSI/Burma
conducts pre‐ and post‐BCC session tests with the target groups to monitor the quality of BCC
sessions. In addition, mystery clients or mystery observers are sent to prevention outreach
sessions, DICs and clinical services to monitor the performance of these activities. Finally, the SI
and Research Department also aggregates data on a semi–annual and annual basis for analysis of
trends and for reporting purposes to donors on intermediate results from program
implementation. PSI/Burma reports results to USAID/RDMA annually.  
An innovation that PSI/Burma has employed in their MIS system is the use of a Unique Identifier
Codes (UIC) to monitor the extent and depth of program prevention coverage of DiC registrants.
The use of an UIC is an anonymous way for program staff to measure individuals reached (rather
than just number of contacts). This system reduces double‐counting and tracks uptake of DiC
services by the client, providing records of service use patterns.
PSI/Burma reported that they periodically send routine M&E program data to the National AIDS
Program in the Ministry of Health. However, this is more on an as–requested basis. There has
been good coordination and collaboration between PSI and the NAP to try and harmonize the
clinical service forms that are used for VCT and STI treatment. A functional national HIV
Monitoring and Evaluation Framework and Technical Working Group do not exist.  
Research
PSI/ Burma conducted TRaC surveys annually from 2004–2008 for FSW and clients of FSW. For
MSM the baseline TRaC survey was conducted in 2008, with a further survey to be conducted in
2010. TRaC surveys have allowed for good assessments of intervention outcomes with respect to
how behaviors, attitudes, knowledge, and beliefs have changed over time in these target
populations. The TRaC surveys are used to monitor behaviors and determinants of behavior and
evaluate behavioral outcomes of the target MARP populations. This information is used for
program design and implementation. For example, the behavioral determinants that are
identified from surveys are used to develop a HIV Marketing Plan, which is the strategic plan
that describes how a prevention intervention project will be delivered. Additionally, these
identified behavioral determinants are used to develop an “audience profile” for each target
population, which is used during program design and implementation. Behavioral determinants
are used to develop key BCC messages and IEC materials. These messages and materials are
tested and then packaged for delivery through appropriate channels.  
In summary, PSI/Burma’s research work assesses the extent of outcomes from interventions and
uses this evidence–base to continually tailor their prevention strategies. TRaC data are regularly
disseminated to all PSI/Burma. However, there is limited sharing of TRaC data with PSI’s
partners. It was reported that TRaC reports are available on the PSI HQ web site. PSI/Burma also
conducts TRaC surveys for their malaria and diarrhea programs.  
In 2008, the Research Team changed the sampling strategy and will now do TRaC surveys every
other year in the same target MARP populations. Since there is a change in sampling
methodology, there will be a break in trends over time from 2004–2008. The 2009 TRaC will now
be the baseline (using the new sampling methodology) and subsequently the 2011 TRaC will
provide the second data point.  
24
Qualitative research and special studies
In 2009 PSI/Burma conducted a small bio‐behavioral study among MSM in the TOP Center in
Rangoon7. Respondents were selected from DiC visitors. The study sample was made‐up of 310
feminine MSM and 340 masculine MSM. HIV prevalence was alarming high in feminine MSM at
41%. Although HIV prevalence among masculine MSM was lower than for feminine MSM (23%),
it was nonetheless high. Gonorrhea prevalence was 7% among feminine MSM and 12% among
masculine MSM. Syphilis prevalence was 11% among feminine MSM and 4% among masculine
MSM. Condom use at last anal sex was low among all respondents (46% for feminine MSM, 42%
for masculine MSM). Nearly half of all masculine MSM had female partners, as opposed to only 3
of the feminine MSM. This small study helped the DiC staff understand the behaviors of their
client population and the rates of HIV and two STIs. Data were analyzed and used to help
strengthen prevention programming for both sub–populations.
In other qualitative research activities, PSI/Burma will be collaborating with WHO to do a client
health seeking behavior survey in 2010–2011.  
PSI/Burma research and SI technical staff have been invited to participate in new national
incidence modeling work that UNAIDS is leading. This work will look at modes of HIV
transmission using the Asian Epidemic Model (AEM) to help supplement the weak national data
coming from NAP BSS and HSS surveys. Additionally, PSI/Burma will be assisting the NAP
Technical Support Group in the next round of population size estimations.
Project MAP
PSI/Burma regularly conducts Project MAP (Measuring Access and Performance) surveys to track
the availability of prevention products such as condoms and lubricant in all MSM and FSW
project sites. In 2008, a MAP study on male condom availability in places where commercial sex
takes place was conducted with geo–references in Mandalay and Rangoon. Locations for
commercial sex were grouped together as hot zones if they were situated within 300 meters of
each other. Lot quality assurance sampling (LQAS) methodology was used, with random
selection of 19 hot zones in each city for outlets selling male condoms. The results of the survey
showed that condom coverage in hot zones in Rangoon was 90% for any condoms and 90% for
PSI socially marketed Aphaw condoms. In Mandalay coverage was 65% for any condoms and
60% for PSI socially marketed condoms 8. These data were used by the condom social marketing
team to make adjustments in program planning.  
PSI/Burma also regularly utilizes GIS mapping to geographically plot its program components.
An example of the application of GIS mapping is illustrated in Figure 2, below. This allows for a
quick snapshot of geographical program coverage. This strategic information tool is useful for
planning program expansion and scale–up, especially when overlaid with epidemiological data.
It can also be used to understand overlaps in geographic coverage by other programs. There are
many uses for GIS mapping and PSI/Burma has the tools and technical expertise to employ it in
its own programming and also provide technical assistance externally.
                                                      7 Data collected from a presentation titled, “Presentation of MSM Survey” that was given to the
Assessment Team by Habib Rahman. 8 2008 PSI/Burma MAP Study
25
Figure 2 9: Example of GIS mapping in PSI/Burma program
PSI/Burma Program Overview
Urban Urban Rural Rural Urban
Retail/Wholesales Outlets 
Mass Media & IPCs
Private GPs Trained community 
members
PSI Staff, MVUs PSI Staff, Peer Educator, 
DiC
Health Product, Health 
Communications and 
Promotion
Health Products & 
Services
Health Products & Basic 
Services
Health Communications, 
Products, and Services
Health Communications, 
Products, Services, and 
Empowerment
HIV, Malaria, Diarrhea RH, Malaria, STI, TB, 
Pneumonia, Diarrhea
Malaria, Pneumonia, 
Diarrhea, RH, STI, TB
Malaria, Diarrhea, 
Pneumonia 
HIV
Social Marketing 
Urban
Social Franchising 
Urban (Sun Clinics)
Social Franchising 
Rural 
(Sun Primary Health Providers)
Social Marketing 
Rural
Targeted Outreach 
Program
294 Townships 
30 Sales Reps
170 Townships 
1,006 Sun Providers
33 Townships 
759 Sun Providers
14 Cities 
37 IPCs 
144 peer workers
Malaria and Diarrhea 
111 Townships 
40 IPCs
 Source: PSI/Burma 
3.4.3 Strengths and facilitating factors
Strong staff technical capacity for conducting research and analysis. PSI/Burma has a strong
internal capacity for conducting strategic information activities. The PSI/Burma staff are seen by
partners as leaders in strategic information and are regularly sought out by government, NAP,
and other stakeholders (i.e., UNAIDS, WHO) for technical support at the national and sub–
national levels. PSI/Burma is a long–standing member of the national HIV Technical Strategy
Group for the Three Diseases Fund and the Global Fund for AIDS, Tuberculosis and Malaria
(GFATM) CCM.
Turning research into action. PSI/Burma routinely turns both program monitoring data and
research into actionable events that are linked directly to improving their programming thus
making their programs evidence–based.  
Supportive leadership and adequate human resources. PSI/Burma has a large strategic
information and research department that is well staffed. There is a special priority that is placed
on strategic information and research that comes from the highest levels of the organizational
structure. This belief that strategic information is necessary, critical, and useful to implement their
programs and demonstrate their performance is to be commended.
Applying private sector approaches/models to international public health. PSI/Burma employs
many private sector approaches/models to their international public health work. These business
practices as well as some broader conceptual approaches (i.e. social marketing, social franchising,
                                                      9
 Presentation titled “Sample MIS Data” provided by the PSI/Burma staff in the Assessment Team
Packet of materials for desk review.
26
“total market approach”, DALY measurement of performance), impose rigor that allows alternate
ways to measure performance of their programs.
3.4.4 Challenges and barriers
Analysis of strategic information is not always tied to advocacy. While strategic information is
used for internal program improvement, it is not always turned into external advocacy messages
with a goal of policy change at the national and sub–national levels. One example where PSI has
successfully lobbied the NAP is the inclusion of MSM in the National Strategy and subsequent
focus as a priority group in the successful Global Fund Round 9 proposal.
Dissemination of PSI/Burma strategic information and research needs strengthening.
PSI/Burma does a good job of disseminating results from monitoring and evaluation and research
internally; however, there has been limited sharing and dissemination of strategic information
externally.
Involvement of community members in evidence–based decision making. Government–
community partnerships are nascent in Burma and there is a major challenge in how to best
involve community members in these processes at a higher level. PSI has strong community
involvement in all phases of program design, implementation and evaluation. As and when
Burma society continues to grow and evolve and natural networks of MARPs communities are
formalized and strengthened, it will be important to engage community members in national
decision‐making processes.
3.4.5 Replication and sustainability
PSI/Burma’s strategic information and research portfolio has a good potential for replication.
These SI and research activities are the foundation of any strong international public health
program as the activities are directly linked back to program implementation and results are used
for decision–making and program improvement.  
The breadth and depth of PSI/Burma’s strategic information and research portfolio is advanced
and currently has the luxury of being highly resourced (both human and financial). This type of
SI structure probably has less potential for replication since it is unique.
Regarding sustainability, the foundation of integrating SI and research with program planning
and implementation is critical and is a model that is sustainable in any disease/public health area
and should be something that all programs endeavor to achieve.
3.5 Program management 
3.5.1 Outline of program management
PSI/Burma is a large organization, employing over 700 people. A significant number of staff are
engaged in field work. PSI/Burma’s head office is in Rangoon, and there are 14 other offices
throughout the country. The organizational structure of the head office consists of six
departments reporting directly to the Executive Director. Those departments are Programs
Support, Strategic Information, Social Marketing, Social Franchising, and Finance. In addition,
there is a Special Advocacy Team and a Finance Monitoring Unit.  
27
The TOP is part of the Social Marketing Department but operates with a significant degree of
autonomy, which is reinforced by TOP staff not being located in the head office. PSI has been
comfortable in supporting a peer driven model for TOP, with suitable accountability checks and
balances.  
3.5.2 Key achievements
Increase access to prevention interventions for MARPs
All peer human resource management system  
PSI/Burma uses an innovative “peer progression model” to recruit, train, promote and retain peer
employees to work in TOP. All positions are recruited from peers and all promotions are filled by
existing staff moving to higher positions. Capacity building is a strong element of this model.
This is the foundation of the overall vision of a sustainable MARP–managed program. When
employees feel invested in their work and feel passionate about serving their community, it
shows in all levels of the performance of the program. A peer staffed Technical Support Unit has
been established in TOP’s Rangoon base to manage the day–to–day technical support to all DiCs
to lead the establishment of new DiCs. Creation of this Unit was necessitated by the rapid
expansion in TOP. The TOP National Director stated that his role has changed over time from one
of management and quality assurance into that of senior technical advisor.  
Value driven
The core guiding principles of the TOP Program are: nothing for us without us; respect and
protection; reducing vulnerability; effectiveness; and evidence to action. This MARP–centered
approach allows PSI/Burma to be creative and think about innovative solutions to providing
adequate and full access to services for MSM and FSW.  
Innovation: FSW Emergency Fund
TOP’s FSW peer staff have come together to create a FSW Emergency Fund among themselves.
Every week the peer staff contribute a small amount of their earnings into this fund. Interest free
micro–loans with a flexible repayment plan are available to FSW peer staff from the Emergency
Fund. To date, all loans have been repaid in full. This strategy is also employed by some of the
PLHA Saturday Clubs to help with emergency needs.
Increase access to care and support for PLHA
Robust private sector health care model
PSI/Burma has created a successful, robust private sector health care model to expand and
increase access to health services and products through the network of over 1,000 doctors in the
Sun Quality Health Network, the Sun Primary Health Network of 776 community health workers,
and through social marketing of health products through pharmacies and non‐traditional outlets.  
Improved enabling environment
Advocacy
PSI/Burma through direct advocacy and technical support was successful in advancing a focus on
MSM HIV prevention services. In the 2003 Global Fund Round 3 grant, there was no MSM
programming. PSI/Burma opened the first MSM DiC in 2004, with USAID support. As a result of
28
advocacy by PSI and others, the National Strategic Plan (2006–2010) included for the first time
MSM as a priority MARP for the National AIDS Program.  
3.5.3 Strengths and facilitating factors
Peer–led workforce and MARP engagement
There is a dedicated and skilled peer outreach, peer volunteer, and TOP Center staff. The peer
model is the critical element that makes the program work because of their ability to penetrate
their own networks and combine peer support and outreach services together with health
information about STI and HIV. Members of the target communities are regularly engaged
throughout strategic planning and implementation processes to ensure their needs are met.  
Productive working relationship with MoH/NAP
PSI/Burma has worked hard to strengthen its coordination and communication with government
entities at the local and national levels. PSI/Burma staff provide technical assistance to the NAP
when requested. Links with local government health services are strong and allow for efficient
functioning, including sending blood, without names, to government laboratories for HIV testing.
(Rapid testing is only conducted at the Rangoon and Mandalay DiCs.)  
Collaboration with other key stakeholders
PSI/Burma appears to have good collaborative relations with other key stakeholders in the
country to coordinate and strengthen access to care, support and treatment for PLHA.  
3.5.4 Challenges and barriers
Collaboration with other USAID CAs
The relationship between TOP and the Alliance’s MSM program is strained. There is a need for
both organizations to make a concerted effort to improve collaboration. There is some overlap in
HIV prevention programming in MSM between the large PSI program and the Alliance’s
program in Rangoon and Mandalay. As the numbers of MSM reached by the Alliance are quite
low, this overlap is negligible. Much better collaboration exists between PSI and Pact.  
Coordination and transparency
There is a clear need for stronger coordination, communication, and transparency at all levels on
the part of USAID and its partners with all of the in–country key stakeholders, which will help
facilitate better collaboration and transparency of programming. This is due, at least in part, to
the continued difficulty in USAID obtaining visas to enter Burma for program monitoring.  
3.5.5 Replication and sustainability
As mentioned previously, PSI/Burma has a vision of sustainability built into how they designed
the TOP Center DiC model, which could at some point when conditions are right in Burma
become independent and transition away from PSI/Burma to stand alone as a local NGO. Already,
the TOP model has been replicated throughout the country with much success and in the future
there are continued expansion plans using Global Fund and other donor funding.  
Although the ongoing involvement of the private sector in HIV and other public health
programming is currently significantly reliant on PSI support, at a minimum this private sector
engagement provides a foundation for sustainability. Specific strategies to enhance sustainability
are needed. PSI/Burma believes that its private sector health model is a sustainable, longer–term
vision to health development as it can provide sufficient scale and efficiency in the delivery of
29
health services. Sustainability is also achieved through community ownership of programs, local
partnerships, capacity building and technical assistance. This type of private sector health model
is aligned with and supports national strategic plans and is not a parallel system. PSI/Burma
believes that this type of private sector model is a viable health programming solution in fragile
states and complex political environments.
3.6 Burma: TB program 
Burma is one of 22 countries that account for 80% of global TB cases. TB is Burma’s second
national priority disease. Multi–drug resistance is found in 4.5% of all new TB cases. The HIV
seroprevalence rate among TB patients is 11%.  
3.6.1 Outline of the Burma TB program
In Burma a large percentage of health services for the poor are provided through the private
sector, including 6,000 private doctors. Diagnosis and treatment of TB by private doctors is
hampered by the cost and lack of knowledge and skills. In 2004, PSI Burma introduced a social
franchising program for TB into its existing franchised network of Sun Quality Health (SQH)
private general practitioners.  
Participating doctors receive an initial three days of training from PSI along with regular training
updates. Quality assurance is provided by visits to SQH clinics by PSI medical staff and
monitoring and evaluation is undertaken by PSI Burma’s head office. PSI has developed a well
designed patient record form to monitor the program, and data is reported to the National TB
Program. Participating doctors are provided with free, branded drugs in complete–treatment
packages which in turn are provided free of cost to patients. The drugs are provided free of
charge by the National TB Program. SQH doctors provide their services free of charge to patients,
with no reimbursement by PSI. Laboratory diagnostic costs are reimbursed by PSI. PSI television
advertisements promote TB treatment. In 2009 advertisements were aired 856 times. PSI also used
print media and radio.
In 2010 the Sun Primary Health (SPH) network joined the TB program. SPH community health
workers are involved in case finding and treatment support at the village level. This has potential
to increase the number of patients seeking treatment and to reduce the patient defaulter rate.  
Cash incentives are provided to poor patients with the aim of reducing the patient defaulter rate
due to the inability of poor patients to afford transportation costs. The equivalent of US $36 is
paid in installments over 10 visits to treatment compliant patients. In 2009, around 8% of patients
received cash incentives. PSI has set a limit of 10% of patients receiving cash incentives. The
objectives of the incentive scheme are to encourage adherence to treatment, prevent the
occurrence of interruption and default, reduce the economic burden on poor patients (e.g. time
off work to see the doctor and transport costs), and increase the smear conversion rate and cure
rate. Initially the incentive was trialed at $12 per patient and only available through some clinics.
There was a low uptake rate as some SQH doctors said the paperwork was not worth the amount
of effort for that level of incentive. In July 2008, as additional donor funding became available, the
incentive was increased to $36 and expanded to potentially include all participating SQH doctors.
An additional transportation fee for rural patients, paid on arrival for scheduled appointments,
was also introduced. Nutritional support is available on an ad hoc basis for registered patients,
depending on donations.  
30
3.6.2 Key achievements
In the six years 2004–2009 a cumulative total of 52,700 TB patients were treated, with increases in
the number of TB patients treated in each year. Currently the PSI TB program is treating around
12,000 cases of TB per year, which is 10% of total national cases. The number of SQH doctors
actively involved in the program has grown each year. By the end of 2009, 676 SQH doctors in
145 townships were involved in the TB program which is the equivalent of 67% of all SQH
doctors.  
In 2008 there was only a small increase in the number of new TB patients despite an increase in
the number of doctors participating in the program. From early 2009, PSI introduced an incentive
of US $2, paid to doctors for newly registered cases. This has resulted in an increase in new
patients.  
WHO’s target for TB treatment success is 85%, with a patient defaulter rate of 5% or less. In the
first year of the program the treatment success rate was 78%. In 2009 the treatment success rate
reached 85%. Defaulter rates for the whole program have been at 6% for most years, but went up
to 7% in two years. In 2007 and 2008 the defaulter rate for the overall program was 6%.
Preliminary data shows that the defaulter rate for incentive cases reduced from 5% in 2007 to 3%
by the end of 2008 after the level and coverage of incentives was increased. In the absence of
increased incentives, the defaulter rate would most likely have been higher. However, it is too
early to tell whether the incentive scheme will succeed in getting the overall program defaulter
rate below 5%. PSI has speculated that to achieve a defaulter rate of 5%, it may need to increase
the coverage of incentives to 20% of poor patients. More SQH doctors would need to participate
in the incentives scheme to achieve this coverage level. While this would significantly increase
program costs, this needs to be weighed against the very high cost of MDR treatment.  
The program requires SQH doctors to routinely recommend that all TB patients have an HIV test.
As private doctors are not permitted to conduct HIV tests this requires referral to a public sector
site, with the exception of Rangoon and Mandalay where PSI has permission to operate two
community VCT sites called QC clinics. The number of SQH TB patients having an HIV test in
Rangoon and Mandalay increased from 5 to 24% between 2008 and 2009 following the
introduction of an incentives scheme that pays US$1.50 to the patient, on arrival at the PSI QC
clinic, for transport costs. The SQH doctor is also paid $1.50 for each TB patient who returns with
a voucher from the QC clinic. Out of 1,260 TB patients who were HIV tested at QC clinics from
January to October 2009, 243 (19%) were HIV positive. The cost of incentives paid to identify one
additional TB/HIV co–infected patient was $15.83. Outside Rangoon and Mandalay, PSI indicates
that the HIV testing rate among SQH TB patients is very low.  
3.6.3 Strengths and facilitating factors
The use of transport incentives and payments to doctors has been successful in motivating higher
referral rates and attendance at VCT clinics in Rangoon and Mandalay. PSI is exploring options to
provide incentives for HIV testing and counseling through public sector providers.  
A very positive feature of the program is that doctors are prepared to give their services freely.
As these doctors benefit from being a part of SQH, this may be a beneficial effect of social
franchising.  
31
SQH doctors provide information to the family members of TB patients regarding drug
adherence and are active in providing information to communities to reduce stigma and
discrimination. Many of the SQH doctors have also initiated their own TB outreach programs to
follow up with patients who interrupt treatment to increase their compliance. In 2006, PSI took
responsibility for paying these outreach workers.  
The SQH TB program appears to be well managed and monitored by PSI. The program has been
modified on a number of occasions with good results in terms of increased treatment success
rates and fewer defaulters.  
3.6.4 Challenges and barriers
National policy restriction on who can conduct HIV testing means that SQH doctors need to refer
all patients to external providers. PSI is advocating for permission to provide routine opt–out
HIV counseling and testing for TB patients at all SQH clinics. It will be difficult to significantly
increase HIV testing rates for TB patients while the current policy restriction remains.  
Around one–third of doctors are currently participating in the incentives scheme, although all are
now able to join component of the program. Some doctors have been reluctant to provide cash
incentives to eligible poor patients as they need to wait some time for reimbursement from PSI.
The managers of the program would like to provide doctors with a cash float for payment of
incentives. However, this has not been permitted by PSI for reasons relating to accountability and
financial risk.  
Follow up with defaulter patients has indicated that reasons for default included family problems,
health problems, migration in conflict zones and alcohol dependency. While the incentive scheme
has reduced the defaulter rate, incentives were not always able to overcome these reasons for
default.  
3.6.5 Replication and sustainability
The average case load of each cohort of trained doctors is stable. This is a good indicator of
continuing commitment to the program by doctors and will assist with sustainability. The
absence of fees paid to doctors may mean that TB treatment services would continue to be
provided by general practitioners should donor funding cease. However, a number of costly
aspects of the program would need to cease.  
Table 4 sets out the cost per patient treated for the years 2007, 2009 and 2010 in relation to the
package of services, incentives and other program enhancements. As additional elements have
been added to the program, the cost per patient treated has doubled since 2007. There was a small
increase in the treatment success rate in 2009. The impact of the revised and expanded incentives
scheme and including SPH in the program in 2010 on treatment success rates are not yet known.  
Table 4: Cost of TB treatment and effectiveness: 2007, 2009 and 2010
Year Cost per
patient
Tx success
rate Program package
2007 $26 83% Free treatment and diagnosis SSM, CXR
2009 $37 85% Plus cash incentives for doctors and adherent patients + nutritional support
2010 >$50 ? Plus Sun Primary Health CHW case finding + support
Source: PSI Burma
32
The SQH TB program has demonstrated that providing large scale free DOTS using a socially
franchised network of doctors is viable. This private sector model has particular applicability to
Burma given the weakness of public sector health system and restrictions on donor funds flowing
to government. The model may have applicability to other countries where these factors do not
apply, as utilization of private sector medical practitioners increases reach and potentially
coverage. Currently there is insufficient data to indicate whether the current configuration of the
incentives scheme will be effective in driving the overall program defaulter rate below 5% and in
increasing the treatment success rate. The program is still in a model development and testing
stage. National program coverage and increased access to TB treatment have improved equity
and treatment outcomes for the poor. The cost per patient treated is high and has grown as
additional components were added to the program. The benefits of the program need to be
balanced against cost and the implications cost have for sustainability. Further model testing
should provide answers in relation to costs and benefits.
33
4. China
4.1 HIV prevalence in China 
HIV prevalence among China’s general population is estimated to be 0.5 percent, with highest
levels in the six provinces of Yunnan, Henan, Guangxi, Xinjiang, Guangdong and Sichuan. HIV
in China is concentrated in certain MARPs: IDU, FSW, and MSM. Over 40% of HIV infections in
China have been among IDU. Surveys of hotspots found HIV prevalence among FSW at 5–10%,
with the highest prevalence in Guangxi, Xinjiang, and Yunnan. Some FSW are also IDU, and
thereby dually at risk. Results from a recent sixty–one city, Government of China survey found
an average HIV prevalence rate among MSM of 5%, with rates as high as 18% in some cities. Key
risk factors targeted by USAID/RDMA implementing partners in China include low condom use
among MSM and low–income FSW, low condom use by MARPs with regular sexual partners,
high rates of sharing needles and syringes among the IDU population, and low personal risk
perception among MARPs.  
4.2 Overview of PSI/China program 
PSI/China implements HIV and malaria programs. HIV activities are exclusively USAID–
supported (apart from one–time support from UNFPA in FY09 for the provision of technical
assistance in social marketing.) Malaria activities are exclusively supported by the Global Fund
Round 5 grant. PSI/China also implemented a one–year safe water program in FY09 through a
public–private partnership with Proctor and Gamble.  
With USAID/RDMA HIV funding, PSI/China supports the Comprehensive Prevention Package
(CPP) through an integrated China work plan, in collaboration with other USAID/RDMA–
supported cooperating agencies (CA)—Family Health International (FHI), the International
HIV/AIDS Alliance (Alliance), the Health Policy Initiative (HPI), and Pact. Together, the USAID
CAs contribute to the implementation of the overall Comprehensive Package of Services (CPS)
model which includes the continuum of prevention, care and treatment. PSI’s role within this
integrated program is focused on model development through implementation of innovative
approaches to HIV behavior change and prevention for IDU and FSW populations, and the
collection and analysis of strategic information to monitor and guide program implementation.  
PSI/China implements HIV interventions which target IDU and FSW in Kunming, Gejiu, Mengzi,
and Kaiyuan in Yunnan Province; and Nanning, and Ningming in Guangxi Province. HIV
activities in Yunnan began in 2003 and activities in Guangxi began in March, 2009. Specifically,
these activities include:
 Highly targeted social marketing of HIV risk reduction products including male and female
condoms, and lubricant;
 Targeted behavior change communications (BCC), and peer outreach with IDU and FSW
through drop–in centers and outreach, plus limited technical assistance to MSM;
 Drop–in centers that provide a safe space for FSW and IDU;  
 Mid and mass media communications for general HIV knowledge and reduction of stigma
and discrimination towards MARPs;
 Referrals and linkages to allow MARPs to access a full range of prevention, care, and
treatment services (CPS model);  
 Capacity building of local partners, grassroots NGOs and the GFATM project sites for
replication of successful interventions;
34
 Project level behavioral tracking among MARPs; and
 Routine behavioral tracking among MARPs in multiple USAID hotspots where CAs
implement (with collaboration from other CAs).
PSI/China collaborates closely with two Chinese government organizations—the Public Health
Bureau (PHB) and the Public Security Bureau (PSB). The PSB is a law enforcement agency
responsible for the compulsory detoxification centers for IDU, making it a key government
collaborator when working with the IDU population. The PHB supports health and other clinical
services.  
The PSI/China program utilizes a different approach from other PSI country programs. In
addition to direct implementation by PSI, sub‐grants are also provided. This includes two sub‐
grants to grassroots CBO‐type organizations in Yunnan, (Sunshine Home in Kaiyuan and
Kangxin Home in Mengzi), both implementing activities for IDU, and three sub‐grants to local
government in Guangxi (Nanning CDC, Ningming CDC, and the Wangzhou Community Center)
for IDU community rehabilitation activities. The Wangzhou work includes support to the
Nanning PSB for implementation of a pilot community rehabilitation project.  
4.3 Prevention 
4.3.1 Outline of the PSI/China HIV prevention program
PSI’s HIV prevention program targets IDU and FSW with the provision of BCC interventions and
other services. BCC interventions focus on decreasing sharing of needles and syringes and
increasing consistent and correct condom use with commercial, casual and regular partners. PSI
is engaged in condom social marketing on a limited scale (i.e., not marketing directly to ‘non–
traditional’ and other outlets, but rather distributing PSI branded condoms through peer
education and outreach activities).  
PSI’s prevention work includes peer education, community outreach, drop–in centers, support
groups and health referrals. Peer educators engage IDU and FSW about the risks of injecting, the
importance of consistent and correct condom use, the promotion of HIV counseling and testing,
and the need for STI screening. Peer educators also work at the methadone maintenance therapy
(MMT) clinics and detoxification centers. Peer educators use a variety of interpersonal visual aids
such as flip charts and leaflets to deliver health messages.  
Drop–in centers for IDU (Huxianghao Ba in Kunming) and for FSW (Sisterhood Health Home in
Mengzi) provide a ‘safe place’ for IDU and FSW to meet and receive BCC messages, access to
VCT and STI services, information on safer drug injection and access to low–cost condoms. PSI
DIC are staffed by trained peer educators.  
PSI has been successful in establishing a model site in Kunming (Huxianghao Ba) for community
based rehabilitation of IDU. Using Huxianghao Ba as a learning site, PSI is beginning to adapt
and replicate the model in other sites, beginning with the Wangzhou Community Center in
Nanning. PSI supports peer education in eight of Yunnan’s compulsory detoxification centers in
collaboration with the PSB/ Narcotics Control Committee Office.
35
4.3.2 Key achievements
Development of best practice prevention models: drop–in centers and peer education
PSI’s two drop–in centers promote the consistent use of high–quality/low cost, branded condoms
with all sexual partners and encourage and facilitate testing for STIs and HIV. Interventions are
based on a peer education approach, with support from IDU volunteers and peer educators.  
The Huxianghao Ba Drop–in Center in Kunming provides a variety of services to its nearly 5,000
members, including confidential VCT services (pre– and post–test counseling and rapid HIV
screening) with referral support to CDC for positive test results; referral to needle exchange
services, methadone maintenance therapy (MMT) and detoxification services; home visits for
peer counseling; IDU family member support meetings; community outreach and technical
support including outreach in five MMT clinics, and peer educator (PE) supervision in
detoxification centers. Huxianghao Ba Drop–in Center PE provide support to community
rehabilitation programs in Kunming.
Efforts are made to contact hidden IDU through outreach activities and draw them into the center.
Huxianghao Ba Drop–in Center cooperates with seven pharmacies to provide clean needles and
syringes to active IDU. Narcotics Anonymous meetings are held once a week, supporting IDU to
stay off drugs. Huxianghao Ba also cooperates with the Law College of Yunnan University to
provide legal assistance to IDU and PLHA. When members fail to visit Huxianghao Ba Drop–in
Center over two to three months, the center contacts members by phone to check on them and
urge them to attend.  
PSI peer educators working through the Sisterhood Health Home in Mengzi conduct outreach
activities four times per week in identified ‘hot spot’ areas of Mengzi. PE report that they are
reaching ‘at least 90%’ of known FSW, including both those based at entertainment
establishments and the more hard to reach, street–based, low–fee FSW. Based on interviews with
member FSW, an excellent rapport between PE and FSW appears to have been created.
The basic PE encounter includes the delivery of information on VCT, STI testing and sale or
distribution of condoms. When making new contacts, PE encourage FSW to access the Sisterhood
Health Home and its services. The center offers free medical examinations once a week by a
doctor from the MCH hospital, with referrals to local health care services, and a VCT service
twice a month. The center is able to track FSW by phone/SMS, alerting them to center–based
activities or reminding them to have health examinations/tests.
Both the Huxianghao Ba Drop–In Center in Kunming and the Sisterhood Health Home in Mengzi
report that they have a good relationship with their community and neighbors. The community
‘admires’ their work, acknowledging that they are providing a service to the community.
As a testament to the effectiveness of PSI’s BCC interventions, numerous individuals—both
government and NGO partners—recommended that interventions be replicated in other ‘hot–
spots’ in China. In particular the drop–in center model was highly appreciated. Many felt that the
government would welcome the roll–out of the PE and outreach approaches developed by PSI
and utilized by the drop–in centers.  
36
Behavior change
Program strategies being implemented are helping to change key behaviors related to condom
use, safe injection practices and uptake of HIV counseling and testing services. Both PE and
beneficiaries claim that rates for safe behaviors have increased as a result of the work carried out
by PSI (Huxianghao Ba Drop–in Center in Kunming and the Sisterhood Health Home in Mengzi).
Needle sharing in Yunnan dropped from 37% in 2004 to 10% in 2009.10 Among FSW, consistent
condom use with all partners increased from 39% in 2004 to 78% in 2008.11 (See Figure 3 below.)
Rapid testing at PSI DiCs increased from an average of five per month in December 2008 to over
25 per month in August 2009 (following introduction of rapid testing services in April 2009). In
addition, the Guangxi Prevention and Treatment of HIV/AIDS Committee Office reported a
decrease in needle sharing and indicated that condom distribution has been effective in reducing
HIV and STIs.  
Figure 3: Behavior change among IDU and FSW in Yunnan, 2004 – 2008/09
Source: PSI/China 
Progress in reaching hard to reach populations
Both the Huxianghao Ba Drop–in Center in Kunming and the Sisterhood Health Home in Mengzi
have been able to increase MARP access to prevention services. PE, outreach staff and PSI
indicated that there is now less interference in their work from community members, government
officials and police. According to government staff interviewed, these ‘hidden groups’ are
extremely difficult for government to contact, let alone influence in any positive way. The role of
PSI and other international NGOs is acknowledged as being critical to reach out to and influence
hard to reach populations.
PSI has been successful in contributing to the intermediate result of “increased access to
prevention services.” During FY2007, (the year preceding the extension of this project), a total of
10,919 IDU were reached through peer education and outreach activities in Yunnan. PSI
                                                      10 TRaC Surveys in Yunnan Detoxification Centers (2004 and 2009) 11 TRaC Surveys among Mengzi FSW (2004 and 2008)
37
increased this number to 15,365 in FY2009. In FY2007, a total of 2,662 FSW were reached through
peer education and outreach interventions in Yunnan. This increased to 3,371 in FY2009 12.  
A mix of traditional and evolving strategies
PSI’s behavior change strategies can be described as a mix of ‘traditional’ and ‘evolving’. The
traditional approach involves the use of PE in drop–in center based and outreach activities in
which information is delivered orally and via IEC print materials. As for an evolving approach,
this is linked to the 2008 drug law which provides for the development of community
rehabilitation for IDU. This new community approach, which involves work with government
officers, IDU and the family of IDU, seems to be well received.
MARP involvement in developing behavior change strategies, messages and materials
In the development of strategies, messages and materials, PE, IDU and FSW involvement is
significant. Determinants of behavior are drawn from TRaC survey results and used to develop
key behavior change messages. IDU and FSW are engaged to make recommendations on
messages, material content and overall design. Draft materials, designed by an ad agency/graphic
design firm, are pre–tested with the relevant MARP and PE.
Overall NGO and government partners who use PSI IEC materials are pleased with their content
and quality; MSF indicated that PSI produces ‘good materials on MMT, safe injection and relapse’.
Improved availability of prevention products
PSI has contributed to improved access within the private sector for HIV/STI preventive products
(condoms and lubricant) and has improved availability and access for MARPs to these products.
Previously PSI handled retailing of branded condoms and lubricants to traditional outlets such as
drug stores and supermarkets. However, as China now has a mature condom market with more
than three hundred manufacturers and around 1,000 brand names, PSI made a strategic decision
to shift to a modified social marketing approach, described below.
The general population in Yunnan and Guangxi have good access to condoms, including an array
of domestic and imported commercial brands and free products distributed by the government.
By PSI’s account, the quantity of condoms in project areas is sufficient to meet existing demand.
However, it is important to point out that there is very little hard data on the overall condom
market in the project provinces.
PSI feels that their initial introduction of subsidized, high–quality, socially marketed condoms
helped to influence the condom market in Yunnan, resulting in a greater variety and number of
condoms and improved quality, with most now displaying ISO certification. MARPs interviewed
confirmed the availably, affordability and quality of condoms available through the private sector.
PSI’s condom promotion interventions have had the most impact on MARPs and ethnic
minorities. The social marketing approach has increased the target group’s understanding and
desire to protect themselves. MARPs are now willing to pay for condoms in China.
PSI now works with a ‘marketing/distribution’ company (via Futures Group) to place PSI
branded condoms with display materials in 2 to 5 star hotels in project areas. In addition, PSI
collaborates with other organizations (FHI, Alliance, MSF, GFATM, AusAID, Clinton and Gates),
providing them with subsidized, branded condoms—30% are distributed for free and the
                                                      12 PSI/China Annual Reports FY2007 and FY2009
38
remaining 70% are distributed via low–cost sales. PSI also provides branded condoms to the local
CDCs. PSI trains staff in social marketing. CDC ‘peer educators’ undertake direct distribution of
condoms through ‘non–traditional’ sites for FSW and other MARPs. In addition, PSI peer
educators distribute condoms at their drop–in centers and during outreach activities.  
Table 5 — Subsidized social marketing of condoms/lubricants—cost/income: 2007–2009
SALES REVENUE*
Jan–Dec 07 Jan–Dec 08 Jan–Dec 09 TOTAL
Condoms–Male 336,046 428,177 497,925 1,262,148
Condoms–Female 0 615 1,473 2,088
Lubricants 7,797 60,397 18,305 86,499
Total sales revenue 343,843 489,189 517,703 1,350,736
Expense COSTS*
Local Salaries 115,944 136,091 153,073 405,108
Travel 5,946 16,939 17,830 40,715
Product cost 236,754 290,264 308,528 835,546
Shipping and
Handling 6,505 6,628 8,363 21,496
Total Expenditure 365,149 449,922 487,794 1,302,865
SURPLUS/(DEFICIT) (21,306) 39,267 29,909 47,871
* Currency is in RMB. US $1 = RMB 6.8. Source: PSI/China
Income from PSI/China condom social is relatively small. The program is still largely subsidized
to cover operational costs as well as human resources. PSI/China uses income generated from
social marketing activities to procure additional commodities and to support distribution costs.
4.3.3 Strengths and facilitating factors
Strengths and facilitating factors include:
 A highly skilled and committed group of peer educators and volunteers working through the
highly popular PSI drop–in centers. The PSI model combines peer support and outreach
services together with health care to address the needs of recovering IDU. This is a model that
warrants replication throughout China.
 A supportive and productive relationship with government partners. In all cases government
officials (Health Bureau and Public Security) indicated they are pleased and impressed with
PSI interventions and technical assistance. All indicated that the PSI approach is effective in
reaching MARPs and that they would be unable to replicate the model on their own.
 Consistent promotion of VCT and STI services in BCC interventions, and availability of basic
VCT, STI and referral services through the drop–in centers.
 PSI’s access to and participation in community based rehabilitation at the request of local
government.
 Links with local government health services (CDC, MMT) allowing for smooth, efficient and
non–discriminatory referrals.  
 Involvement of MARPs in the development of IEC resources and program interventions.
4.3.4 Challenges and barriers
While the PSI program has realized success in several areas, and has been recommended for
replication in other areas of China, there remain some challenges and barriers that PSI and
partners (government and NGO) need to focus on.
39
 Condom use by IDU and FSW with regular partners is still low (although there is no issue
with availability of quality condoms). IDU and FSW are reluctant to approach their regular
partners about condom use. They want to hide their past/current situation (i.e., as a sex
worker or drug user) from regular partners. Attitude change will require a significant and
sustained IPC approach.
 FSW feel that putting the onus on them for ensuring consistent condom use is not a balanced
approach. FSW suggest that future HIV awareness and prevention interventions also focus on
their clients. An independent set of materials and approaches will need to be designed to
target clients in an effective way.
 Behavior change is a long–term process. PE must spend consider time working personally
with IDU to ensure/guarantee solid change. This will require a sustained commitment by both
PSI and the government.
 While MARP involvement in material development is a notable achievement, it appears that
new IEC materials have not been developed in the past one and a half to two years. Several
PE and MARPs from both the Sisterhood Health Home and the Huxianghao Ba Drop–in
Center indicated that new, innovative IEC materials needed to be developed. It was claimed
that the FSW and IDU were ‘getting tired’ of receiving the same information on HIV over and
over again. New materials need to contain information on topics other than HIV as well as try
out new delivery systems (i.e., use of new technologies such as cell phones and the internet).  
 Many MARPs are still reluctant to access VCT services, either for fear of receiving a positive
result or concern with the name based, non–confidential system, given current Chinese policy.  
 While the community rehabilitation program has helped to sensitize many about drug use
and HIV, many IDU and PLHA sill prefer not to reveal their status to partners/family. More
counseling and psychosocial support, with links to care, support, and treatment, is needed
 MMT adherence could be improved. PSI is currently developing new IEC materials and
approaches to work with IDU.
 Stigma and discrimination towards IDU, FSW and PLHA are still high among groups not
touched by PSI and other partners. This may require the development and delivery of a
creative and sustained mass media campaign focusing on the general population.
 Reaching migrant populations remains an issue. Innovative approaches and resources need to
be considered.
 Members of the Huxianghao Ba Drop–in Center and the Sisterhood Health Home feel that
centers need to ‘diversify’ their activities by offering job skills training (such as computer and
office skills) and job placement assistance. Without such diversification the appeal of the
centers may wane.
4.3.5 Replication and sustainability
There is concern regarding the replication and sustainability of PSI approaches. Undoubtedly the
work carried out by PSI peer educators, volunteers and outreach workers is effective—indications
are that condom use has increased, needle and syringe sharing has deceased and more
individuals are accessing STI, VCT and MMT services. The community–based, MARP–friendly
approach that PSI utilizes is essential to China. However, given that interventions are financially
supported completely by PSI, sustainability and adherence to the model remains a question
under potential government management. Can the government pay an equivalent salary to PEs,
and more importantly, will PEs trained by PSI be allowed to work in a creative and supportive
environment with the government? USAID needs to take these concerns into consideration when
planning for replication.  
40
It is clear from interviews with government officials that sustaining the PSI model would be
difficult for both financial and methodological reasons. PSI brings a level of ‘humanity’ to the PE
and behavior change process which the government may not be able to replicate. Several
government staff indicated that it would be ‘difficult to continue without PSI support’.
However, considering the enthusiastic support by the government for the PSI interventions and
acknowledging the growth and enthusiasm of Chinese civil society groups, it may be reasonable
to imagine that the replication of PSI approaches could be attained via a partnership between the
government and local civil society groups. Such a melding could help obtain international donor
support and establish partnerships/working agreements with appropriate Government agencies.
Beyond that, local civil society groups may, on their own or within an alliance of like–minded
civil society groups, seek international and/or national donor support in order to replicate PSI
approaches and programs. This approach may be more appropriate in continuing and potentially
advancing the humanitarian approach practiced by PSI outreach teams targeting MARPs.
Most interviewees also commented that PSI needs to do a better job of communicating with
government officials in order to increase visibility of this successful approach, to support the roll–
out of the model to other areas of the country and to leverage financial support from government
sources.  
4.4. Strategic Information 
4.4.1 Outline of key strategic information activities
PSI has a robust and multi–functional strategic information system in China. The monitoring and
evaluation (M&E) system includes collection and analysis of data at all levels, from activity
monitoring to outcomes. The following outlines the major activities for PSI/China’s M&E system.
Program level quality assurance  
PSI/China adheres to quality assurance methods built into its data collection system that are
standardized across all PSI countries. Protocols have been established for quality assurance in
interviewer training, questionnaire translation, data collection, data entry and data cleaning. An
example of data quality assurance for activity–level data from the Huxianghao Ba Drop–in Center
includes monthly comparison of paper records with computer entries to ensure that the two
match. Another example of data quality assurance for programs includes focus groups that are
conducted when activity monitoring flags a possible issue in uptake of services. In terms of
quality assurance for data analysis, given the poor data environment in China, results from
population–level studies are triangulated with national surveys from the China CDC and
UNICEF as much as possible.
Activity monitoring
PSI/China uses a web–based Health Management Information System (HMIS) to collect a variety
of information on activities in their drop–in centers and for outreach activities. A client unique
identification code is used to enable the identification of the number of individuals reached.
Routine activities such as the number of visitors to the drop–in center, VCT visits and educational
sessions are tracked in the web–based HMIS. Several pieces of information are recorded for each
VCT client, including whether they received pre– and post–test counseling, test results, and what
referrals were given to the client. In addition, information on support activities provided by peer
educators in community centers, MMT clinics and detoxification centers is also collected.
Trainings given and attended by staff are recorded in the HMIS, including technical assistance
41
provided to partners. A key feature of the HMIS is the tracking of referral cards given by staff
compared with the referral cards collected from referee sites at the end of each month. This
theoretically allows PSI to track how many of the referrals given are actually used. The web–
based platform for the HMIS allows authorized users to enter information from any computer
with internet access, whether at project sites or in the main office in Kunming. The HMIS is also
programmed to build reports on selected items, thereby facilitating trends analysis and allowing
for managers to quickly view the status and uptake of activities.
Routine behavioral monitoring (internal)
Tracking Results Continuously (TRaC) is the primary behavioral monitoring survey tool
employed by PSI in the sites where it is implementing. It is designed to inform programming by
the routine collection of data from targeted populations. PSI/China uses these surveys to provide
information about the target population’s behaviors, behavioral determinants, source of products
and service delivery, and exposure to PSI’s programs. TRaC also helps to measure the
effectiveness of PSI’s interventions and activities. The TRaC is performed by PSI/China’s research
team based in Kunming, with the help of interviewers hired locally. The data analysis is also
performed by the research team in Kunming. Several TRaC surveys were undertaken over the
course of the USG–funded project, with the goal of routinely tracking the behavioral outcomes of
targeted IDU and FSW. TRaC surveys for IDU in Yunnan and Guangxi were performed in 2004,
2006, and 2009. TRaC surveys for FSW in Yunnan and Guangxi were performed in 2005 and 2008.  
The Routine Behavioral Tracking (RBT) survey is another way that PSI, in collaboration with
other CAs, will conduct behavioral monitoring in 2010. The purpose of the survey is to establish a
baseline and a model for future surveys of the FSW and MSM populations in Yunnan and
Guangxi, and to provide programmatic and behavioral monitoring information for USAID–
supported interventions provided by multiple USAID‐supported CAs in those provinces. Data
gathered will be used to report against key monitoring indicators and to provide program donor
and partner organizations with a comprehensive evidence base for further work with these
populations.  
In 2009, USAID requested that PSI take the lead role in developing the methodology and
coordinating the RBT survey for USG–funded FSW and MSM programs in Yunnan and Guangxi,
including those implemented by other cooperating agencies. PSI will take the lead role in
measuring the reach and effectiveness of the FSW and MSM programs in program sites using a
survey based on its TRaC tool and incorporating sampling and experience from other
methodologies and data collection, such as the FHI’s behavioral surveillance survey (BSS). The
data gathered through the 2010 RBT survey will be analyzed according to PSI’s Performance
Framework, presenting results in the “Dashboard” format. The Dashboard is a set of
standardized tables for segmenting populations, monitoring trends in key population and service
delivery indicators, and evaluating program effectiveness. Data from the 2010 RBT will also
provide a risk profile for MARPs. Results from the Dashboard analysis will be used in strategic
project planning. It is envisioned that the RBT methodology may be adopted for measuring the
effectiveness of the USAID–supported CPS model for MARPs in other countries.
Periodic outcome monitoring (external)
HPI will oversee an external assessment of the USG–funded IDU services in Yunnan and
Guangxi and document the model for possible replication. The work will be undertaken via two
simultaneous tracks, delivering preliminary results from both processes by June 2010. The full
studies will be completed in September 2010. HPI sub–contracted with an international
42
consultancy firm to provide technical leadership, and a local Chinese research institute will
support data collection. Track one will consist of a qualitative study of IDU services in USAID–
support sites, with the following objectives, using an adaptation of the Appreciative Inquiry
methodology:
• To describe the IDU model in substantial detail, including development of a collective view of
the model, its inputs, outputs and outcomes, key indicators and influences on outputs
• To assess the achievements, strengths, shortcomings and weaknesses of the IDU activities in
the framework of CPS implementation in Guangxi and Yunnan
• To develop, collectively with CAs, strategic recommendations to improve key IDU activities
implemented in CPS.
Track two will consist of a risk behavior survey that will be an adaptation of a survey tool already
available in Chinese. The study will make comparisons in risk behavior between CPS IDU service
clients and non–clients and between sites where CPS IDU services are available and matched sites
where no services are available.  
Annual performance review
An annual performance review is conducted by PSI/Washington where the China program is
compared to other country programs based on the use of a “dashboard” tool. This annual review
also includes the possibility of incentives for country programs that are performing well
compared with other countries where PSI has a program.
Surveillance
PSI/China does not participate in HIV surveillance activities.
4.4.2 Key achievements
• Through the TRaC survey and RBT described above, PSI/China collects information on
behavioral determinants of the target groups. The collection of this information is an
innovation in routine behavioral monitoring and gives insights to PSI for the adjustment of its
program and changes in the target population’s needs. The RBT will enable this process to
also include other CAs and enhance the integrated USAID approach.  
• The TRaC also allows PSI to collect information that demonstrates attribution of
improvements in health outcomes directly to PSI programs. The PSI China program was able
to use TRaC survey data to demonstrate the effectiveness of its programs in increasing
condom use among FSW, decreasing needle–sharing and increasing condom use among IDU,
and increased uptake of VCT services due to PSI programs.
• PSI/China has taken a leadership role in the implementation of the RBT, which includes
adapting the TRaC survey and coordinating other USG partners to provide excellence in
behavioral monitoring for MSM and FSW in Yunnan and Guangxi.
• The PSI China program uses data to make decisions and change course in its program
activities. Figure 4 below provides specific examples of how data was used to take action in
PSI’s program.
43
Figure 4: Use of data to make decisions
   Source: PSI/China 
4.4.3 Strengths and facilitating factors
• PSI as an international organizational places an emphasis on evidence–based programming.
This provides a worldwide network of support for continued excellence in the collection and
analysis of strategic information at the country level.  
• The PSI/China team and PSI as an organization has a high technical capacity for undertaking
research activities. All survey design and data collection can be completed by PSI’s research
team in China. There is a strong internal technical capacity that is mostly led by Chinese
nationals.
• Through the TRaC and RBT surveys, there is close monitoring of target populations.
• In addition, the TRaC surveys allow for segmentation of target populations that tracks
behavioral determinants for improving programming.
4.4.4 Challenges and barriers
• PSI/China faces serious constraints in contributing to the data base on HIV in China due to
Chinese government policies and practices on sharing results of its annual HIV
epidemiological surveys. Most data on HIV and MARPs is labeled as confidential by Chinese
officials and, when results are shared, their validity cannot be verified. Data collection
methods and survey questionnaires are not shared. In addition, external organizations must
received permission from the Chinese authorities to conduct any epidemiological research.
Therefore, the reliability of data on the epidemic in China is uncertain.
• In addition to the relative lack of available data on HIV in Yunnan and Guangxi, the human
rights situation in China, especially for MARPs, creates a more complicated environment for
even the routine behavioral surveys undertaken by PSI. MARPs are suspicious of
participating in such surveys due to poor experiences with China CDC’s surveillance
methods. MARPs report being forced to participate in China CDC surveillance activities
including the use of biomarkers, results of which are usually not shared with the individual.
44
• PSI headquarters requires PSI/China to collect information that is not always relevant to its
program. This is a constraint on PSI/China’s flexibility in designing and managing its own
M&E system.
4.4.5 Replication and sustainability
• PSI/China’s SI activities are not replicable without PSI technical assistance to develop the
capacity of partners. Currently, all SI activities are undertaken internally by PSI staff. 13
• The newly–initiated RBT will be jointly implemented by PSI and other USG–funded CAs.
Despite some knowledge and skills transfer to the other CAs in the process of developing and
implementing the RBT, PSI plays the leading role and it is as yet uncertain whether other CAs
will be able to perform the RBT without PSI’s assistance.  
4.5 Program Management 
4.5.1 Outline of program management
PSI has a total of 45 staff in China, 25 for the HIV program and 20 for the malaria program, with
the main office located in Kunming, Yunnan Province. Staff in Kunming includes a Country
Director, social marketing advisor, a training team, a technical team including experts on BCC
and FSW and IDU programs, and a research team. The training team was established following
the 2007 USAID award as there was a crucial need for dedicated training staff. PSI has identified
and trained several peer educators who are essential to success of the program. These peer
educators are paid a salary by PSI and are considered to be full‐time PSI staff. In addition, PSI has
a small office in Nanning (three staff) in Guangxi Province. Staff from PSI’s Kunming office travel
to Nanning every month to conduct trainings and project oversight. It was noted that additional
staff would be helpful, particularly as staff turnover is currently high.  
Unlike the PSI/Burma and PSI/Lao HIV programs, the PSI/China HIV program is exclusively
USAID/RDMA–supported. PSI/China is planning to transition and close down activities as of
September 30, 2010 when the current agreement with USAID finishes. The forthcoming end of
this project and uncertainty of job security has affected morale and many staff have left PSI/China
over the past several months. This has resulted in numerous vacancies and increased
workload/fatigue among the staff that remain. In addition to the normal workload, PSI staff have
been significantly involved in several USAID reviews of the China program over the past several
months.
4.5.2 Key achievements
Development of a model learning site
PSI has been successful in establishing a model site for the community based rehabilitation of
injecting drug users IDU in China. This site, the Huxianghao Ba DiC, is directly implemented by
PSI in Kunming and has been branded and socially marketed as a package of services through a
community led and implemented model for IDU. PSI has hosted study tours for government
officials to visit and learn about the Kunming site and has provided on–site training by staff from
Huxianghao Ba at potential new sites. A key achievement is that the Huxianghao Ba community
model is currently being adapted and replicated by the government in Nanning and through this
                                                      13 It should be noted that the finding regarding the sustainability of PSI’s strategic information activities in China 
is different from the findings regarding the sustainability of PSI’s strategic information activities in Burma and 
Lao. This is because the strategic information activities in China are quite different to those in Burma and Lao. 
45
process, is informing the implementation of the community based rehabilitation outlined in the
June 2008 Anti–Narcotics Law. In this collaboration, the government finances the cost of the
center and PSI supports the salaries and training of the peer educators who work to replicate the
Huxianghao Ba model. While this partnership ensures greater government collaboration, there is
a high level of fear and distrust (due to perceived stigma) among IDU in using a government–run
center. PSI is assisting the government in marketing and designing the center to be more “IDU–
friendly” and similar to their Huxianghao Ba learning site. In addition, other organizations, such
as Day Top, have adopted and opened similar DiCs. PSI has been proven to be successful in
experience sharing and learning in the model replication process.
Capacity building
PSI’s approach to capacity building and technical assistance in China as well as other countries is
unique. The capacity of partners is developed through an approach of “leading by example”
through direct implementation rather than short term technical assistance provided from a
distance. PSI’s strategy for capacity building and long term approach to technical assistance,
together with their evidence–based programming, has proven to be effective. For example, PSI
was among the first INGOs to demonstrate to the Chinese government that the introduction of
HIV rapid tests will increase uptake of VCT among MARPs and consequently, screening rapid
tests have been adopted by the government in select sites over time.  
Evidence–based programming
Using, their own TRaC methodology, PSI has quantitatively proven the impact of their programs
to the government and has been asked to work in new areas. For example, PSI was the first INGO
to be able to work inside the IDU detoxification centers. PSI has successfully partnered with the
Guangxi Public Security Bureau (through a MOU) and collaborated with the Yunnan Public
Security Bureau to be able to provide peer outreach activities and peer educator trainings inside
the detoxification centers. PSI led the way and has provided technical assistance to AusAID and
other NGOs on work inside the centers. Other examples of how PSI’s internal use of data has
garnered more support include:
• UNFPA has requested technical assistance from PSI for the training of government staff in
two provinces in the area of social marketing franchising.
• WHO has requested technical assistance from PSI on social marketing services and products.
PSI is exploring future collaboration with WHO.
• AusAID has requested PSI technical assistance for training inside the detoxification centers.  
• PSI secured Global Fund Round 5 monies for malaria. PSI’s high performance in malaria,
along with targeted advocacy, was recognized by the Chinese government.  
Community–driven program planning
PSI works together with local target communities in developing work plans. PSI believes that
MARPs must be involved in the planning process to ensure that activities are relevant and
appropriate. PSI also engages community leaders, family members and key individuals in
program development and planning. PSI has developed excellent relationships with these
individuals and organizations and they are comfortable approaching PSI directly regarding
programmatic needs and changes.  
46
4.5.3 Strengths and facilitating factors
Involvement of MARPs
PSI deploys MARPs as staff which has been a critical component of their success in China.
Members of the MARP target population are engaged throughout the planning process, ensuring
that the program is continuously redefined to meets their needs. For example, new facilities were
added to the Huxianghao Ba DiC (weight room, baby room) at the request of IDU clients. As a
result of this MARP–involved approach, PSI staff is considered as ‘family’ to the clients. The
inclusion of IDU in rehabilitation activities has also helped to decrease stigma in the communities.
PSI was commended by many government partners, for their exceptional ability to deeply
penetrate into the MARP population.  
Technical excellence
PSI’s expertise lies in technical support in peer education, training and innovation in behavior
change communication. PSI’s work with the IDU community has been timely and responsive to
the June 2008 Anti–Narcotics Law. The Chinese government and communities require
considerable technical assistance in how to implement this law and PSI, as an INGO with
expertise in the IDU population, is well suited to assist. PSI’s technical training at the
government–run Wangzhou Center has improved the relationship of IDU with the local
community and family members.  
Strong working relationships with strategic local government counterparts
PSI has developed strong relationships with the local government. Examples include:
• Establishment of an memorandum of understanding (MOU) with the Public Security Bureau
in Guangxi and a technical assistance partnership in Yunnan, resulting in PSI’s ability to
provide peer education activities and training in the IDU detoxification centers in both
provinces. PSI is the only INGO to have a relationship with the PSBs.
• Through a partnership with the local maternal and child health (MCH) hospital, PSI is
bringing critical health services to FSW in Mengzi. A MCH doctor comes to PSI’s Sisterhood
Health Home DiC once a week, increasing access to health services among FSW and
strengthening the link to government health services.  
• In Nanning, PSI organizes regular project meetings in the Wangzhou community with the
Public Health Bureau (PHB) and other INGO partners (MSF, etc) to coordinate on program
planning, provide an update on project progress, and make future plans.  
Collaboration with USAID/RDMA CAs
PSI’s collaboration with the Health Policy Initiative, International HIV/AIDS Alliance (Alliance),
and Pact has strengthened during the last two years. PSI and HPI have many complementary
program areas related to IDU and harm reduction. Since the June 2008 Anti–Narcotics Law, PSI is
leading on the implementation of community based rehabilitation for IDU, while HPI is leading
on operational policy processes related to the law. There is also close collaboration on the IDU
impact evaluation that HPI is undertaking and HPI’s work on the establishment of a legal center,
where PSI refers many clients. PSI, HPI, and the Alliance collaborate at the site level through their
support to Kangxin Home, where PSI focuses on BCC training, Alliance on community
mobilization and capacity building, and HPI on capacity building in the area of advocacy. PSI
also collaborates with Pact on livelihood programs for IDU, where PSI refers clients to Pact’s
livelihood program. PSI’s collaboration with FHI is weaker and noted under the challenges and
barriers section below.
47
4.5.4 Challenges and barriers
CA collaboration
In 2004, in response to the request of the Chinese government to have one single point of contact
for the USAID program, RDMA asked FHI to serve as the coordinator for all USAID CAs in
China. The decision to have one CA to serve as the coordinator for other CAs, particularly a CA
that has a key role in implementation, has proven to be problematic and resulted in a strained
relationship between FHI and all the CAs. Collaboration among the CAs, not including FHI, is
strong, but collaboration among the CAs and FHI is weak. This is not an issue that is exclusive to
the PSI program.
PSI and FHI have both developed separate programs for FSW and IDU in China. There is no
overlap at the site level as CA support to the sites is divided by hotspot. However, FHI and PSI
should build on each others work on IDU and FSW programs in China and share experiences and
information, such as IEC materials. Specifically, there is a clear opportunity for FHI and PSI to
collaborate at the Jinhudong Green Garden Community Center for IDU in Geiju as PSI is
providing outreach into the detoxification center near Geiju and can refer to FHI’s community
center. This collaboration has been initiated and should be encouraged.
There is a distinct benefit to a collaborative joint programming approach in the implementation of
the comprehensive prevention package in China. However, there is a need for a neutral entity to
serve in the coordination role. This should take the form of stronger USG coordination at the
provincial level to ensure the implementation and integration of the program and clear
delineation of each CA’s role.  
USG involvement in Beijing
There is a need for more USAID support at the national level in Beijing. In order for the USG to
successfully move to a technical assistance model in China, USAID/RMDA must advocate and
seek buy–in for the USG China CPP model with the National Center for AIDS and Infectious
Diseases (NCAIDS), UNAIDS, and other donors. USG involvement in Global Fund mechanisms
at the national level is required to advocate for provincial level Global Fund resources. PSI
advocates at the provincial level to the extent possible, however, few resources are available at
this level and decision making occurs in Beijing. Involvement by USAID CAs at the provincial
level alone will not result in successful leveraging of Global Fund resources.  
Communication with the provincial governments
More regular and proactive communication between PSI and the provincial governments needs
to occur to ensure joint programming and collaboration. PSI’s communication with the Guangxi
HIV and AIDS government offices is minimal, however, it should be noted that the program in
Guangxi is new.
PSI has a strong link to the PSB, however, a stronger communication mechanism with the Public
Health Bureau (PHB) needs to be established. This appears to be a weakness for many NGOs in
China. While PSI submits reports on a semi–annual and quarterly basis, as requested by the
government, follow up meetings to discuss the reports, in addition to regular progress updates,
are needed. It also appears that internal communication systems within the Chinese government
may be weak as INGO progress reports are not routinely shared. Sharing of information between
government offices (PSB and PHB) is difficult. Higher level of government engagement is needed
48
between PSI and the government so that the impact of PSI’s program can be conveyed for
advocacy purposes.
Limited focus on community involvement from the Government
Community mobilization and involvement is not central to the Chinese Government response to
HIV and AIDS. The Guangxi government is more open to work with IDU and therefore is
allowing PSI to work in local communities, whereas the Yunnan government is more closed. PSI
successfully negotiated an MOU with the Guangxi PSB to help implement the June 2008 Anti–
Narcotics Law, focusing on community rehabilitation. PSI has established a less formal technical
advisory role in Yunnan, where they work in 7–8 detoxification centers and support community
rehabilitation.
Management challenges
Due to turnover of PSI staff over the past year, the management of the PSI/Sisterhood Health
Home FSW DiC is weak. PSI, in discussion with the FSW peer educators, enhanced the outreach
component of the program and subsequently modified the hours of the DiC, so that it is only
open 2 days week (Thurs–Friday). However, this has resulted in far fewer FSW participating in
DiC activities (2–5 FSW/day compared to 10–15 FSW last year) as activities inside the center are
often cancelled. FSW that were interviewed were unhappy about this change and felt that they no
longer have a safe space.
4.5.5 Replication and sustainability
PSI builds sustainability through its focus on overall health impact and behavior change, based
on disease area with an overall goal to improve quality of life. Those individuals who have been
trained by PSI may continue to be involved in HIV work beyond the life of the PSI project.
However, success in China is highly dependent on an enabling environment. An effective
MARP–friendly response in China requires a quality assurance/technical assistance role provided
by an NGO. There is still a large gap in technical capacity in HIV in China, particularly in the
areas of community involvement and mobilization, capacity building, human resources, and
innovations in approaches to achieve behavior change. There is a clear need for USAID to
provide technical assistance in these areas as well as quality assurance to government funded
programs.  
In future, Huxianghao Ba can serve as a learning site from which technical assistance on
implementing a community based rehabilitation program for IDU can be provided.  
However, if the PSI program ends, there will be no human capacity or enhanced technical
capacity for the DiC. The Wangzhou Community Center will continue as it is supported by the
government, however important technical innovations (peer education, training to government
social workers) that PSI provides to help make the site more MARP–friendly will not continue.  
Should USAID financial support end, it appears that the Mengzi government is willing to take
over the PSI supported Sisterhood Health Home DiC for FSW, however county level resources
for FSW programs in Mengzi are scarce. In addition, technical assistance through peer education
and outreach training would be required for success of the DiC.  
While PSI’s employment of peer educators is key to the success of their program, it also presents
an issue of sustainability beyond the support of an INGO. Due to budget constraints, the
government is not able to provide a comparable salary to peer educators, making it unlikely that
49
the highly–skilled peer educators will work for a government program and thereby further build
the capacity of the government.
50
5. Lao 
5.1 HIV prevalence in Lao 
Lao PDR continues to have low HIV prevalence in the general population, estimated at 0.2% in
the 15–49 age group, despite being surrounded by countries with significantly higher HIV
prevalence. Among MARPs, HIV prevalence rates are highest among MSM (5.6% in a 2007 study
from Vientiane), and lower among FSW, who in the latest IBBS were found to have prevalence
rates in the 0–2% range depending on the province.14 The potential for significant increases in
these rates is demonstrated by high rates of STI infection that have been documented among FSW
(30%) and MSM (40%).15
5.2 Overview of PSI/Lao program 
PSI/Lao’s main projects are:  
• National condom and lubricant social marketing (CSM)
• HIV/STI reduction with MSM, focused on transgenders and their partners in Vientiane,
Savanakhet and Luang Prabang
• HIV/STI reduction with sex workers in Vientiane and seven other provinces.  
• Malaria reduction in three provinces
• A study to determine whether insect repellant reduces malaria incidence, taking place in 2
provinces
• Social marketing of other products such as water purification tablets
USAID support to PSI/Lao is only for its HIV program. In 2009, PSI received approximately $1.3
million in total from a range of donors for its HIV program. Around 20% of these funds were
from USAID, focused on HIV prevention with MSM in three provinces. With additional Global
Fund Round 8 monies, USAID’s contribution to PSI’s HIV work will be reduced to around 15%.
PSI’s malaria funding is from the Global Fund.  
5.3 Prevention 
5.3.1 Outline of the PSI/Lao HIV prevention program
The PSI/Lao strategy is to focus its HIV work with MSM, FSW and clients of FSW, to prevent the
spread of HIV. PSI/Lao has two specific evidence–based prevention projects: the New Friends
MSM/TG Project and the You and Me Project for Lao FSW. This Assessment did not see or review
the You and Me Project due to time constraints. The main focus of the Assessment’s field review
was the New Friends MSM/TG Project.  
The 2007 MSM study which found a high HIV prevalence of 5.6% among MSM in Vientiane16,
(the highest measured HIV prevalence in Lao), highlighted the lack of focused HIV programming
for MSM. USAID/RDMA decided to segment responsibility for implementation of its MSM
programming in Vientiane. PSI/Lao was to utilize its USAID funding primarily to focus on
delivering a minimum package of HIV/STI prevention products and services to the visible
transgender (TG) sub–population and the Burnet Institute was to focus its limited USAID
                                                     
14 2008 Lao PDR MoH Sentinel Surveillance Survey
15 2008 Burnet, MoH/CHAS MSM/TG Survey 16 Ibid.
51
funding on programming with the less visible/hidden MSM with a masculine/normative male
identity. At the time, this was a good planning strategy to avoid duplication of services and to
increase overall access to different MSM sub–populations. Outside of Vientiane, PSI targets MSM
more broadly attracting TG, their partners and other masculine MSM. Similarly, segmentation of
the FSW target population happened between PSI/Lao (FSW at karaoke, hotels, nightclubs and
guest houses) and FHI/Lao (FSW at drink shops).
New Friends MSM/TG Project
The PSI/Lao New Friends MSM/TG Project is aligned to support the Lao National HIV/STI
Prevention Program. PSI/Lao used USAID funding to leverage additional support from the
Global Fund and PSI’s YouthAIDS Fund to launch three drop–in centers where MSM can access
quality HIV/STI prevention services. The New Friends MSM/TG Project is carried out in Vientiane,
Savannakhet and Luang Prabang. The project’s target is for 1,200 Lao TG and 4,800 male partners
in these cities to have increased access to VCT and STI services, pre–packaged STI treatment kits,
and condoms and lubricants. The project aims to reduce HIV/STI prevalence through the
following key activities:  
• intensive peer–led behavior reinforcement campaigns (BCC) through three drop–in center
(DiC) sites and outreach;
• targeted STI management and HIV VCT at DiCs;  
• referral to HIV care, support and treatment services;
• social marketing of condoms, lubricants, and STI kits; and  
• advocacy to reduce stigma
You and Me Project for Lao FSW
In Year 3 Implementation (1 Oct 2009–30 September 2010), PSI/Lao combined support from
USAID and Global Fund to expand its outreach to FSW. Currently, the You and Me Project for Lao
FSW is implemented in eight sites (Champasak, Savannakhet, Vientiane Capital, Vientiane
Province, Luang Prabang, Udomxai, Sainyabuli, and Khammuan). Key prevention activities are
similar to the MSM/TG prevention project and include:  
• BCC activities on peer outreach;  
• referral for clinical services (STI management and VCT);  
• referral to HIV care, support and treatment services;
• social marketing of condoms, lubricants, and STI kits; and  
• advocacy to reduce stigma
5.3.2 Key achievements
Increased access to prevention interventions for MARPs
Peer–led behavior reinforcement campaigns (BCC)
In January 2010, the New Friends MSM/TG Project was operating with 196 staff (both full–time
staff and peer educators) in three cities. The major element of this HIV prevention program is a
strong peer outreach component in all three intervention sites. PSI utilizes a “peer progression
model” to engage community members in various roles ranging from field outreach peer staff to
core DiC staff. Currently, almost the entire field and some of the core staff at the DiCs come from
the target community. Primary exceptions are for technical specialists such as the clinic doctors,
laboratory technician, and other technical and administrative positions. This commitment to the
“peer progression model” contributes fundamentally to the creation of a space that is geared to a
genuine sense of belonging for clients where they can receive and give support to one another
52
during outreach and at the DiCs. It is clear that peers are at the heart of creating a foundation
where support for their community is central to building an environment where MSM interact
with peers and other DiC staff to engage in health seeking behaviors in a way that leads to better
health outcomes. The peer educators are trained and certified by the Ministry of Health’s Center
for HIV/AIDS and STIs (MoH/CHAS). Additionally, PSI/Lao provides more in–depth training as
needed on special topics specific to the target population.
Peer outreach activities include: education and communication, IEC materials distribution,
condom and lubrication sales, information about DiC, and most importantly friendship and
community building. The peer outreach is conducted every night of the week in beer gardens,
beer shops, salons, discos, other entertainment sites. Each peer educators has an assigned
zone/hot spot. Peer outreach workers reported that they regularly meet repeat clients as well as
new clients during outreach. The BCC messaging is grounded in HIV prevention basics for both
repeat and new clients, with sessions for new clients taking longer than for repeat clients. With
repeat clients, the sessions are more like conversations, with the opportunity to answer questions,
which primarily relate to STI symptoms and VCT. Initial contact with clients are primarily made
through outreach, with a significant number of clients subsequently visiting the DiC, especially in
Luang Prabang.  
PSI/Lao conducts pre‐ and post‐BCC session tests with the target groups to monitor the quality of
BCC sessions. In addition, mystery clients are sent to prevention outreach sessions, DICs and
clinical services to monitor the performance of these activities.  
Additionally, PSI/Lao is on the cutting edge of development of innovative new BCC interventions
for its MSM target population. In January 2010, PSI/Lao launched its new national project
utilizing mobile phones to promote VCT and BCC.  
Condoms and lubricant
PSI/Lao is the national leader in social marketing of condoms and water‐based lubricant, with the
support of the Global Fund. Condoms are widely available in pharmacies and non–traditional
outlets near hot–spots (bars, discos, hotels, and guest houses). MSM and FSW condom use rates
have risen. From 2004 to 2006, condom use for any sex in the last week by MSM went from 24%
to 41% 17. For the behavior, ‘ever used water–based lubricant for anal sex’ for MSM, use increased
from 55% to 86%. Surveys of FSW showed similar increases in consistent condom use, except for
consistent condom use with trusted partners, which decreased from 48% in 2005 to 46% in 2008 18.  
DiCs and targeted clinical service delivery
DiCs are another key element of PSI/Lao’s HIV prevention program. In 2009, with combined
funding from USAID, the Global Fund, and PSI headquarters, the New Friends MSM/TG Project
opened three DiCs, thus significantly expanding access to quality HIV and STI prevention
information and services for MSM, including TG. The DiCs also provide pre– and post–test
counseling, rapid HIV testing, STI management and treatment, and referral to clinical care and
ART services. DiC clinical services are provided by PSI/Lao hired medical practitioners. DiCs
have created a safe place for community members, providing an environment for social
interaction and community building. The DiCs also provides an opportunity for access to the
                                                      17 2004 and 2006 TRaC MSM Survey; data from slide presentation given by PSI/Lao Director. 18 2005 and 2008 TRaC FSW Survey; data from slide presentation given by PSI/Lao Director.
53
internet, entertainment, recreation, other information/education activities (i.e. small group
discussions, skits, role playing, etc.) for a large number of MSM.  
The 2008 size estimate for MSM was 15,000 19. For the calendar year 2009, the New Friends
MSM/TG Project reported reaching, through a combination of activities (outreach activities, DiC
visits, and STI and VCT clinical services), a total of 7,296 20 individual clients. The total number of
new clients was 4,443 (61% of all contacts). A total of 2,853 individuals were contacted on a repeat
basis (39% of all contacts). The total of 7,296 MSM reached represents 49% of the estimated MSM
population.  
PSI/Lao was successful in obtaining approval from MoH/CHAS to conduct VCT rapid testing at
their MSM DiCs. This is a significant achievement as Lao is one of the first countries in the region
to allow rapid testing at DiCs, using the international standard two rapid test algorithm
(Determine and Unigold). Figure 5, below, shows the number of MSM/TG having VCT by month
at the three DiCs during the last 5 months of the 2009, when this service was introduced. A total
of 790 21 HIV tests were performed in the three DiCs, or an average of 154 tests per month. This
exceeded PSI/Lao’s target of 500 tests by 290 or 140%. Use of a VCT incentive scheme for peer
outreach workers seems to be a significant factor in the high rate of HIV testing. The incentive
system pays $20 to each peer outreach worker who brings in 1–10 people for VCT. The incentive
doubles to $40 to each peer outreach worker who brings in 11–20 people.  
Figure 5: Targeted VCT for MSM/TG
    Source: PSI/Lao 
Voluntary Counseling and Testing for HIV
for MtF Transgenders
17
107 106
406
154
0
50
100
150
200
250
300
350
400
450
August September October November December
Number of TG who received VCT
PSI/Lao data on MSM/TG utilization of STI clinical services at the three New Friends DiCs indicate
a total of 121 clients received STI treatment in 2009. The breakdown of clients was 35 new TG; 1
repeat TG; 81 new partners; and 4 repeat partners 22. These figures only represent those who
received treatment. It is not clear from the data whether additional people are coming for an STI
check‐up but who do not need treatment. PSI/Lao uses a syndromic approach for the diagnosis of
STIs. A more detailed analysis of the STI clinic data at the Luang Prabang DiC indicates that
almost 100% of clients who attended the STI clinic presented with STI symptoms. If this is also
                                                      19  2008 National Estimation Group, Size Estimation for MSM used in the Global Fund Round 8
application. Information provided by PSI/Lao via e–mail. 20 PSI/Lao New Friends MSM/TG Project Monthly Report Jan–Dec 2009 Final (excel spreadsheet). 21 PSI/Lao New Friends MSM/TG Project Monthly Report Jan–Dec 2009 Final (excel spreadsheet). 22 PSI/Lao New Friends MSM/TG Project Monthly Report Jan–Dec 2009 Final (excel spreadsheet).
54
the case at other DiCs, clients are only coming for STI screening when they are showing
symptoms. Given the limitations of the syndromic approach, it is unlikely that additional cases of
STIs would be diagnosed if clients with asymptomatic STIs presented for check‐ups.  
The 121 clients who received STI treatment in 2009 is about 1.6% of the total number of
individuals reached by New Friends in that year. The number of MSM/TG seeking STI treatment is
considerably lower than the number seeking VCT (790 in the last 5 months of 2009). The
experience in other countries in the region is that larger numbers of MSM seek VCT compared to
STI check‐ups. In Lao, the incentive paid to outreach workers for VCT may be the reason for the
considerably higher numbers seeking HIV testing, compared to STI check‐ups. However, as VCT
only commenced at the DiCs in August 2009, the initial high utilization figures may not be
sustained. It would not be feasible to introduce an incentive for STI check‐ups using a syndromic
approach as attracting clients with no symptoms would not result in a significant number of
additional STI diagnoses.  
PSI markets a single dose STI treatment kit (‘One Stop’ brand) for males through pharmacies,
supported by the Global Fund grant. PSI trains pharmacies in the correct dispensing of this
product.  
The above analysis indicates that within a short period of time both the reach as well as service
utilization by MSM has increased significantly in all of the intervention sites covered under New
Friends MSM/TG Project. This success can be attributed to the process of community mobilization
that New Friends has adopted as a core strategy. This process starts with the building of trust and
confidences among peers, project staff, and the community members. The increased use of
preventive services by MSM is also an indicator of strength of the peer outreach components of
New Friends.  
Increased access to care and support for PLHA  
Referral to HIV care and support services and treatment
The PSI/Lao New Friends MSM/TG Project currently does not provide HIV care, support and
treatment services at the DiCs. However, any HIV‐positive clients found through VCT are
referred to government clinics where ART is provided with Global Fund support. By January
2010, only three clients had tested HIV positive at the DiCs. All three clients were escorted and
linked directly to government ART services, thereby ensuring a continuum of prevention to
treatment for those PLHA. Care and support services are nascent in Lao and it is not clear who is
providing these services. The Assessment Team concludes that the PSI/Lao program cannot
adequately address or show results for increased access to care and support, as opposed to
treatment.  
Strengthened enabling environment
Advocacy to reduce stigma
PSI/Lao held the first “public forum” with Lao TG in December 2008. Members of the community
and representatives from civil society and the public sector attended. It was reported by many
peer staff and clients that because of the New Friends MSM/TG Project there has been a shift in
people’s attitudes toward MSM and TG. Clients say that the DiC is a place they enjoy coming to
to socialize with their friends and they are successful in getting their partners to come with them
to use the DiC’s services. One program staff member reported that success for him is that the
55
members of the target communities trust the New Friends MSM/TG Project staff and they are open
to having in depth discussions regarding HIV, condoms and sex.
5.3.3 Strengths and facilitating factors
Peer–led workforce and MARP engagement
The outreach and DiC components are the backbone of the program. PSI/Lao has dedicated and
skilled peer outreach and DiC staff. The peer model is the critical element that makes these
activities work. Peers have the capability of penetrating their social networks to access members
of their communities and to combine peer support and outreach services with health information
about STI and HIV. Members of the target communities are regularly engaged throughout the
strategic planning and implementation processes of the program.  
Prevention interventions are evidence–based
The New Friends MSM/TG Project BCC campaigns are evidence–based as PSI/Lao regularly
conducts Tracking Results Continuously (TRaC) surveys to monitor behaviors and determinants
of behavior and evaluate behavioral outcomes. There is good use of strategic information from
these surveys which is directly linked to the refocusing (if needed) of BCC messages and the
development of new, relevant, and nuanced BCC messages that better target the behaviors of the
target population. Reports from focus interviews with clients suggest that the BCC messages
provided during outreach are appropriate. (See 5.4 below for more on strategic information.)
Incentive scheme for peer outreach work
PSI/Lao uses incentives in two ways for outreach (using Global Fund resources) and for
recruitment of people to VCT. In both instances, the incentive schemes have been successful in
increasing client usage of the DiC and uptake of VCT. The incentive scheme should be
continuously monitored and assessed for unintended consequences (see 5.5.3, Challenges and
barriers, below).  
5.3.4 Challenges and barriers
• Currently in Lao, there is no specific guidance on feminization issues for TG. Based on
interviews with the clinical doctors at the DiC and a review of a draft external assessment
report23, there is a need for more training on the feminization issues for TG and their medical
needs.
• USG Leadership: Strengthen USAID oversight and management of country programming. It
was reported that increased monitoring trips and in‐country support from USAID/RDMA
would be welcomed.
• Condom use by MSM and FSW with regular partners is still low. There is a need to develop
creative and innovative BCC/IEC approaches to address this.
• Uptake of female condoms by MSM is low. There is the option of promoting female condoms
to MSM/TG, similar to what is being done by PSI/Burma. However, given the higher cost and
therefore higher subsidy of social marketed female condoms compared to male condoms, this
would increase program costs.  
• Many MSM are still reluctant to access STI services. In particular, MSM who attend the STI
clinic at the PSI DiC in Luang Prabang are routinely advised to go to the public sector STI
                                                      23 Draft Report: External Review of the 100% Condom Use Programme and Sexually Transmitted
Infection Services in Selected Sites in Lao People’s Democratic Republic (June 2009)
56
clinic for syphilis testing. However, few do so because of long waiting times at the
government clinic and the cost. Although the prevalence of syphilis in Lao is low, PSI should
seek expert technical advice on whether rapid screening for syphilis should be introduced
into its STI protocol.  
• Stigma and discrimination towards MSM/TG, FSW and PLHA is still high.
• DiC activities could be diversified (e.g. income generating activities, job skills, English classes,
etc.).
5.3.5 Replication and sustainability
PSI/Lao’s New Friends MSM/TG Project is successful and there is a high degree of replication and
sustainability for many of their HIV prevention approaches. The work carried out by PSI peer
educators, volunteers, and outreach workers is effective and the community–based, MARP
focused approach that PSI utilizes is essential for Lao.  
The outreach incentive scheme is being promoted by Global Fund and will most likely be
replicated in the future. The GFATM funding that PSI/Lao will receive will be sufficient to carry
on this incentive scheme for outreach.  
For longer term sustainability, there is a question as to whether the Lao government could ever
take over a program like this since the funding for health and HIV are all donor based. The VCT
incentive scheme has potential and has shown some early results in increasing the uptake of VCT
by members of the community. As the project completes its final year on this grant, it will be
important for USAID to monitor closely the results from January to September, 2010.
PSI/Lao is moving toward building a “total market for health products”. PSI/Lao has been very
successful in the social marketing of condoms, lubricant and STI kits. They are now trying to
build a market for a broader range of prevention products that would be sustainable without
long‐term PSI support.  
5.4 Strategic information 
5.4.1 Outline of key strategic information activities
This sub‐section reviews the strategic information activities contained in the PSI/Lao annual
workplans for the period 2007‐2010. An outline of these activities is Annex 5. The strategic
information activities undertaken by PSI/Lao are similar to those undertaken by PSI/Burma. See
section 3.4.1 above for and outline of these key strategic information activities.  
5.4.2 Key achievements
Increased access to strategic information
PSI/Lao places a strong emphasis on improving its internal monitoring systems and use of the
information collected for program planning and implementation, as well as disseminating best
practices and evidence–based program information. Data flow from routine program M&E is
logical to ensure a good continuous feedback loop of information to all levels of the program.
57
Project MIS System and data flow for the New Friends MSM/TG DiCs
Routine program data are collected through a Project MIS system. Client participation data are
collected through paper–based systems by peer outreach workers and DiC staff. Clinical service
data are also collected through paper–based systems by the staff doctors and laboratory
technicians. Data are aggregated and cleaned on a weekly basis and entered into an excel
spreadsheet by a staff member at each DiC. These data are reviewed on a weekly basis by the
PSI/Lao DiC National Coordinator. If any service delivery issues are identified through data
analysis, the DiC Manager works with New Friends DiC staff and peer outreach workers to
implement changes. DiC routine program data are also aggregated on a monthly basis and
displayed on whiteboards within the DiC for clients and peer staff to see monthly performance.
These monthly data reports are also sent to the PSI/Lao HQ where the Director reviews the
aggregated reports for all DiCs. The PSI/Lao Research Team reviews and cleans aggregated data
and does follow–up data quality checks with individual New Friends DiCs if data do not look
correct. The Research Team also aggregates data on a semi–annual and annual basis for analysis
of trends and for reporting to donors. PSI/Lao reports results to USAID/RDMA annually.  
An innovation that PSI/Lao has employed in their MIS system is the use of a Unique Identifier
Code (UIC) which is allocated to each individual who attends a DiC. The use of an UIC is an
anonymous way for program staff to measure the number of individuals reached, rather than
simply just the total number of DiC visits. The UIC can also be used to track the uptake of DiC
services by individual clients, record patterns of attendance and can reveal whether or not the
client is reached regularly.  
As a Global Fund recipient, PSI/Lao periodically sends routine M&E program data to the
Ministry of Health. Lao does not have a national M&E framework for HIV and AIDS and nor is
there a functional national M&E Technical Working Group.  
Research
PSI/Lao has strong internal technical capacity for strategic information. Through analysis of
survey data, PSI/Lao has established behavioral determinants for programming.  
PSI/Lao conducted a baseline TRaC survey for FSW in 2005 and then conducted a follow–up
TRaC survey in 2008. PSI/Lao conducted a baseline TRaC survey for MSM in 2004 and then
conducted a follow–up TRaC survey in 2006. PSI/Lao is now moving into second generation
surveillance with the planned 2010 TRaC survey for MSM that will be conducted in collaboration
with MoH/CHAS. This will include biomarkers for HIV and STI. PSI/Lao also conducts TRaC
surveys for malaria.  
Regular implementation of TRaC surveys has allowed for assessment of intervention outcomes
over time with respect to how behaviors, attitudes, knowledge, and beliefs have changed in
target populations. The TRaC surveys are used to monitor behaviors and determinants of
behavior and evaluate behavioral outcomes of the target MARP populations. This allows close
monitoring of the MSM and FSW populations to establish behavioral determinants for program
design and implementation. For example, the behavioral determinants that are identified from
various track surveys are used as the basis of the creation of a Health Impact Plan, which is the
strategic plan that describes how a prevention intervention project will be delivered. Additionally,
these identified behavioral determinants are also used for the development of client “archetype”
for each target population for use in program design and implementation.  
58
Behavioral determinants identified through the TRaC surveys are translated into key messages
and IEC materials. New messages and IEC materials are tested and packaged for delivery
through the appropriate channels. For example, between 2004 and 2006, there were significant
increases in the following behaviors: condom use at last anal sex with casual partners, condom
use at last sex with boyfriends and use of water–based lubricant during anal sex 24. PSI/Lao
responded by refocusing BCC communications specifically on the topic of improving consistent
condom use and proper use of lubricant during anal sex with all types of partners as well as
efforts made to improve knowledge and correct misconceptions about HIV and AIDS, STIs, and
condom use, and lubricant use among TG.  
PSI/Lao’s research work assesses the extent of outcomes from interventions and uses this
evidence–base to tailor prevention intervention strategies. TRaC data are regularly disseminated
internally to all departments at PSI/Lao HQ, however, there is limited sharing of TRaC data with
external partners.  
Another research innovation is the way PSI/Lao is measuring the performance of their Malaria
Eradication Project by monitoring health outcomes at the village level. Disease monitoring is
done externally by trained MoH doctors who do random blood draws using lot quality assurance
sampling (LQAS). Project performance is measured by the degree to which the prevalence of
malarial disease has changed since the previous year. PSI/Lao is on the cutting–edge by
measuring “health impact”. PSI would like to monitor the health impact of its HIV programs in a
similar way. With the addition of biomarkers for HIV and STI in the next round of the MSM
TRaC survey, PSI/Lao will get closer to this goal of measurement of health impact.
Special studies
PSI/Lao will continue to develop its second generation surveillance work by conducting a pilot
survey in 2010 to track Gonorrhea and Chlamydia rates among FSW.  
Project MAP
PSI/Lao regularly conducts Project MAP (Measuring Access and Performance) surveys to track
the availability of prevention products such as condoms and lubricant in all MSM and FSW
project sites. Project MAP is the main tool that PSI/Lao uses to ensure MARP access to HIV
prevention products when and where they are needed. Project MAP uses GPS satellite
technology and the WHO’s Health Mapper software to track product availability in hot spots.  
The 2009 Project Map study found on an overall basis that PSI Number 1 condoms were available
in 76% of traditional and non–traditional outlets, demonstrating high market penetration. In
Vientiane Capital, 80% of outlets within 1,500 meters of a MSM and FSW hotspot (bar/nightclub,
hotel, guesthouse) stocked Number 1 condoms, 25 An illustrative example of the application of
Project Map in Bokeo Province is shown in Figure 6.  
                                                      24 PSI/Lao Research Brief — HIV Prevention Programming among Transgenders: Lessons from Lao
(December 2008) 25 PSI/Lao 2009 Project MAP Report (Early Draft)
59
Figure 6 26: Project MAP and GPS
Source: PSI/Lao 
5.4.3 Strengths and facilitating factors
Leadership
The Country Director places high priority on using strategic information to guide program
development and implementation. This belief that strategic information is necessary, critical, and
useful to implement their programs and demonstrate their performance is to be commended.
Turning research into action
PSI/Lao is a national leader in data/strategic information use. PSI/Lao routinely turns both
program monitoring data and research into action linked directly to improving their
programming, thus making their programs more evidence–based.
Applying private sector approaches/models to international public health
PSI/Lao employs many private sector approaches/models in their international public health
work. These business practices as well as some broader conceptual approaches, (i.e. social
marketing, “total market approach”, DALY measurement of performance), impose a rigor that
allows alternate ways to measure performance of their programs.
5.4.4 Challenges and barriers
Analysis of strategic information is not always directly tied to advocacy
PSI/Lao collects a tremendous amount of data from their strategic information and research
activities. While it is commendable that this information is used for improving PSI programs,
                                                      26 PSI/Lao — USAID EoP Evaluation Presentation (11 Jan 2009)
60
findings are not translated into advocacy with external partners to guide policy and
programming by others at the national and sub–national levels.  
Dissemination of PSI/Lao strategic information and research needs strengthening
PSI/Lao does a good job of disseminating results from monitoring and evaluation and research
internally; however, sharing and disseminating strategic information externally is limited.
Involvement of community members in evidence–based decision making
There is a need to strengthen government–community partnerships in Lao so that community
members may participate in the analysis and synthesis of strategic information to make decisions
about HIV programming and policies at levels higher than program implementation. To facilitate
community involvement in planning and decision‐making, those infected and affected by HIV
need to have an educated voice in determining the scope, depth, and content of HIV prevention
programming. In order to do this, the capacity of community members to understand strategic
information and how it can be used is critical.  
5.4.5 Replication and sustainability
PSI/Lao’s strategic information and research portfolio has a good potential for replication. These
routine M&E/SI and research activities are the foundation of any strong international public
health intervention program as the activities are directly linked back to program implementation
and results are used for decision–making and program improvement at the project level. The
only activity that may be harder to replicate more widely is the use of HIV and STIs biomarkers
within the TRaC survey for MSM and FSW. This is an innovative new activity to try and measure
disease burden as well as behavior within the same population and PSI/Lao will only be piloting
this in 2010. Close monitoring of this activity will be needed in order to ascertain feasibility for
replication.
The foundation of integrating SI and research with programs is critical and is a model that is
sustainable in any disease/public health area. All programs should endeavor to reach this level of
integration.  
5.5 Program Management 
5.5.1 Key achievements
Management
PSI/Lao has developed strong internal management systems with good feedback loops. This
ensures that progress and any problems or issues are closely monitored by the management team,
with a focus on resolution.  
Leverage of funds
PSI/Lao has a strong orientation to leveraging additional funds from a range of donors to scale–
up its HIV work and to expand into other public health areas. PSI/Lao is receiving approximately
17% of all Global Fund monies for HIV and malaria programming in Lao. In addition to
enhanced funding flows to PSI, PSI has provided broader support for the development of
proposals, resulting in additional funding for other partners. PSI is an active member of the Lao
CCM.  
61
Private sector capacity building
PSI has conducted capacity building for private sector pharmacists to improve their dispensing
practices for STI pharmaceuticals, particularly for PSI’s branded STI kits. Mystery client surveys
are also used to monitor the quality of dispensing. PSI capacity building of the private sector in
relation to condom social marketing has also been a significant achievement.  
Condom social marketing
PSI/Lao estimates it currently has around 58% of the national condom market. PSI’s CSM work in
Lao has significantly increased the size of the total condom market (i.e. the number of people who
buy condoms) and made condoms and lubricant available at an affordable price to the people of
Lao. PSI/Lao has a strong focus on operating in a way that encourages new private sector entrants
into the condom market. In earlier years, PSI sold condoms at a very low price of less than US
$0.10 per pack. This was necessary to build the market as condoms had not previously been
marketed or used in much of Lao. PSI reports that the condom market has changed in recent
years, with many people, including MARPs, being prepared to buy quality condoms at higher
prices. This has allowed PSI to increase the price for some PSI condoms. The reasons for the
increased prices is primarily to ensure that low‐priced socially marketed condoms do not prevent
new private sector commercial condom brands from entering the market. A secondary benefit is
to generate additional income that be can be channeled back into the CSM program. Importantly,
PSI has maintained a low price for on its ‘base brand’ condom (Number 1 Deluxe) to ensure
access for the most poor and vulnerable. In the interests of sustainability it is encouraging to see
that non–PSI private sector condoms are starting to enter the Lao market at all price levels.  
PSI is currently in the process of contracting out national distribution of condoms to a private
sector specialist. This function, which is currently done in–house, will allow PSI’s sales team to
concentrate on development of non–traditional sales outlets.  
In FY 09 PSI/Lao collected approximately US $45,000 in income from condom social marketing.
This money is primarily used to procure more products and to support distribution costs for CSM.  
PSI holds annual workshops in priority provinces (around half of Lao’s 15 provinces) with
Provincial Coordinating Committees for AIDS (PCCA), other government agencies such as police,
and a broad range of social franchising outlets, including pharmacies, entertainment
establishments and other types of non–traditional outlets. On occasion the provincial Governor
has attended some of these workshops. The purpose of the workshops is to review progress and
conduct advocacy for the private sector to be allowed to continue with social marketing of
condoms. This is especially important in provincial Lao where social attitudes can be
conservative. There has been some disagreement between PSI and MoH/CHAS on the best
approach to advocacy on condoms with provincial government officials. This points to the need
for improved communication and coordination between PSI and MoH/CHAS.  
MoH/CHAS has requested technical assistance from PSI/Lao on quality assurance systems for
condoms.
5.5.2 Strengths and facilitating factors
Incentives
PSI’s Lao program is highly innovative, especially in the area of incentives. Incentives for peer
educators have resulted in a higher than expected increase in HIV testing among MSM/TG. PSI is
considering whether it would be feasible to introduce incentives for peer educators, based on
62
population health indicators. For example, basing incentives on a reduction in STI prevalence
among MSM/TG in a defined geographic area. A similar approach has been taken at the village
level with PSI’s malaria program where PSI staff are rewarded for reductions in the prevalence of
malaria.  
Technical assistance models
PSI/Lao takes a broad approach to capacity building and technical assistance, with a strong
emphasis on on–the–job mentoring, learning by doing, and self–directed learning, with a lesser
emphasis on training.  
Relations with other USAID implementing agencies
In Vientiane, PSI is responsible for HIV prevention programs for TG and feminized MSM, and
Burnet, under a sub–grant from Pact, is responsible for programs targeting MSM with a
masculine or normative identity. This segmentation of the target group appears to be working
effectively and there are good and cooperative relations between PSI and Burnet. However, in
Luang Prabang, where Burnet is not working, PSI appears to be reaching a broad range of MSM.  
Similarly, for FSW, FHI/Lao is responsible for programs targeting FSW in drink shops and
PSI/Lao for FSW in karaoke, nightclubs, hotels and guest houses. This delineation appears to be
working well, although there appears to be a low amount of cross–fertilization between the two
projects. Reports and interviews confirm that there are some strained relations between PSI/Lao
and FHI/Lao. This may in part be attributable differences in organizational cultures to how the
agencies interact with the government at the national and sub‐national levels. PSI’s orientation is
more towards working with other partners through the Global Fund CCM, rather than with CAs.
As FHI is not on the CCM, this hinders collaboration. However, there is a fresh opportunity to
forge new working relationships between PSI and FHI.
5.5.3 Challenges and barriers
Relations with the Lao Government
The Global Fund principal recipient in Lao is in a separate section of the Ministry of Health than
CHAS. This arrangement has resulted in some tension between CHAS and the PR. As a recipient
of Global Fund monies, PSI has invested significantly in its relationship with the PR office, but
less so with CHAS. While MoH/CHAS reports that relations with PSI have improved and are
generally good, MoH/CHAS is of the view that there is room for further improvement through
more regular communication and a clear understanding of PSI’s annual work plan. The lack of a
USAID presence in Lao may also have contributed to less than optimal communication between
MoH/CHAS and PSI. An annual meeting between MoH/CHAS, USAID and USAID funded
cooperative agencies (CA) to outline annual work plans and budgets would facilitate improved
relations. This could be followed up by quarterly meetings between MoH/CHAS and all CAs or
individual CAs.  
In Luang Prabang, the only province visited by the Assessment Team, the Provincial
Coordinating Committee for AIDS (PCCA) reported good relations with PSI. The Provincial
Health Department Director suggested convening regular biannual meetings with PSI to review
lessons learned.  
Incentives
PSI needs to be mindful of possible unintended distortions resulting from incentives. In other
countries there is evidence of incentive payments resulting in health workers targeting lower risk
63
individuals to meet targets, meaning those most in need of services are not reached. Incentives
need to be designed in such a way as to avoid this possibility.  
The payment of incentives to peer educators based on the numbers of persons who come for VCT
has resulted in a significantly greater number of MSM/TG presenting for VCT. There is the
possibility that peer educators may be sharing the incentive with clients to encourage them to
have VCT. Incentives need to be kept at low rates to minimize this possibility. PSI is also
providing at least some MSM/TG with t–shirts and caps for having VCT. As these products have
a monetary value, this could be regarded as paying for HIV testing, which raises ethical concerns,
especially with clients who are poor.  
Quality assurance for VCT and STI clinical work
Quality assurance systems in place for PSI’s STI and VCT clinical work include:  
• A PSI developed HIV and STI testing algorithm.  
• Trainings and refresher trainings by the MoH.  
• Periodic government oversight of VCT clinical work.  
• Ad hoc (infrequent) VCT site evaluations using experts from PSI’s US headquarters.
• All HIV positive test results and 10% of negative test results are sent to the MoH for test kit
quality assurance purposes.
• Use of PSI’s internal monthly and quarterly reporting to identify and solve issues.  
• FHI’s regional Technical Advisor for Sexual and Reproductive Health has ad hoc input to
PSI/Lao, in response to requests. His inputs are highly valued by PSI. These take the form of
telephone calls and infrequent in‐country meetings. FHI’s Technical Advisor has not been
involved in training for PSI clinical staff or ongoing assessment of clinical service provision.  
It was not possible for the Assessment Team to evaluate the quality of training or MoH periodic
oversight of VCT.  
Similarly, it was not possible for the Assessment Team to evaluate the quality of PSI’s STI clinical
work. There are, however, significant concerns with the adequacy of PSI/Lao’s STI quality
assurance systems that relate to the absence of periodic on‐site oversight of the STI clinics. Good
quality STI services require a combination of effective training, with an emphasis on both clinical
and social aspects of STIs in MSM and FSW, plus expert supervision of clinical practice. Even
with good training, there is no guarantee that clinicians will provide quality services as there is a
high likelihood of reverting to former poor practices. Ongoing regular supervision should
involve quarterly visits by an STI expert to all clinics to observe clinical practice and provide
feedback. This should be accompanied by clinical record audits and inspections of clinics to check
for things such as the expiry date of drugs and test kits and the availability and use of essential
equipment. The Assessment Team does not have any information on the quality of STI training in
Lao. At present there is no system for regular supervision of STI clinical work. This issue needs to
be addressed by PSI. FHI has indicated that it does not have the capacity to provide regular
monitoring of PSI’s STI work at the clinic level. It is not known whether sufficient technical
expertise exists within Lao and would be available to undertake this function. If external technical
assistance is needed it should have a strong orientation towards building the capacity of local
experts so this function can in time be carried out by nationals.  
PSI Lao has identified the following priorities for STI technical assistance, in priority order:  
1. STI prevention and treatment among MSM (highest priority) and FSW (lower priority).  
64
2. Treatment protocols (clinical and syndromic) for staff at DiCs/clinics.  
3. Drug resistance issues.  
4. How to measure health impact.  
Community mobilization
PSI Lao has indicated that it would prefer to work on a sub–grant model with CBOs for
implementation of HIV/STI programs, rather than these programs being directly implemented by
PSI. Given government restrictions on the development of civil society in Lao, this approach is
currently not possible. However, by developing the capacity of MARPs to implement programs,
capacity for sustainable programs is being developed, with the exception of organizational
development.  
5.5.4 Replication and sustainability
Apart from the PSI Lao Country Director who is also the Chief of Party for the cooperative
agreement, other management positions are filled by Lao nationals. PSI capacity building of these
nationals has contributed to the sustainability of this program. Similarly, capacity building of
peer educators will result in ongoing capacity beyond the life of the programs.  
PSI capacity building in the area of strategic information has been largely internally focused on
PSI staff. These staff have built up considerable technical expertise. PSI could play a useful role in
capacity building of other partners. PSI’s joint surveillance work with MoH/CHAS, however, is a
good example of working with other partners on strategic information in a way that may produce
sustainable results.  
As noted above, PSI’s condom social marketing has been undertaken in a way that encourages
private sector entrants into the condom market, which will assist with long term sustainability.
65
6. Thailand
6.1 Overview of HIV in Thailand 
During the 1990s, Thailand was a global leader in HIV prevention and through programs and
policies like the “100% Condom Program” were able to reduce HIV prevalence significantly
among FSW and the general population. These efforts were not sustained, and by 2000
prevention programs received just 8% of the national HIV budget—significantly less than during
the previous decade 27. Among FSW, some of the behavior change achieved in the 1990s began to
erode, with declining rates of condom use, rising rates of STI transmission and a move from
brothels to street‐based or freelance work which were not reached by prevention efforts.
Additionally, the prevention needs of MSM were largely ignored. In Bangkok, HIV prevalence
among MSM rose from 17% to 31% between 2003 and 2009. With the approval of Global Fund
Round 8, FSW, IDU, MSM and migrants are target groups for targeted HIV prevention activities.
6.2 Overview of PSI/Thailand program 
USAID’S agreement with PSI (2007–2010) originally included activities for Thailand. However,
due to unexpected budget cuts to USAID’s Thailand HIV program, financial support for the
PSI/Thailand program ended in FY08, shortly after this agreement with PSI began, resulting in
the closure of PSI/Thailand’s office. Therefore, the original activities outlined for PSI/Thailand in
the proposal were not formally evaluated during this end of project review.  
Prior to FY08, PSI/Thailand implemented a HIV prevention program for IDU with DiCs in
Bangkok, Chiang Mai, and Chiang Rai (’Ozone’ project) and a HIV prevention program for the
transgender population in Pattaya (‘Sisters’ project). The IDU activities ended in FY08, but
limited support continued to PSI/Sisters for capacity building and technical training through
USAID agreements with Pact and FHI. In FY09, PSI successfully leveraged Global Fund resources
and became the Principal Recipient for IDU activities under the Thailand Global Fund Round 8
grant. PSI has now reopened their office in Thailand and is supporting IDU activities through the
Ozone project which were originally started with USAID support. PSI is also the sub sub–
recipient for MSM activities (with support to Sisters for transgender activities) under Global Fund
Round 8 grant.  
USAID/RDMA’s programmatic priorities in Thailand involve providing technical assistance and
capacity building to USG partners implementing HIV programs for MSM including male sex
workers (MSW) and TG in Bangkok, Chiang Mai and Pattaya. The Assessment Team met with
the new PSI/Thailand Country Director and visited the PSI/Sisters project.  
6.3 Prevention 
6.3.1 Outline of Thailand prevention program
The PSI/Sisters project promotes HIV prevention and overall sexual health for Pattaya’s
transgender population. The PSI/Sisters project focuses on ‘sustaining long–term behavior change
among transgenders through a peer–driven behavior change communication program in
geographic hotspots’. The behavior change communication strategy delivers knowledge on HIV
prevention through outreach to bars and other entertainment establishments, home outreach, and
                                                      27 UNDP, 2004. Thailand’s Response to HIV/AIDS.
66
a drop–in center that provides individual counseling, HIV and STI prevention information, VCT,
skills building, and referrals to sexual health services. The Sisters Drop–in Center serves as a safe
social and recreational space for transgenders.
6.3.2 Key achievements
Development of best practice models on HIV/STI prevention — Sisters DiC
Sisters DiC provides a ‘safe place’ for the transgender population (TG). The center’s mission is to
change the attitudes and behaviors of transgenders who are at risk for HIV and other STIs by
providing information together with the distribution of condoms and lubricants.
The main services of the Sisters DiC include center based activities and peer education/outreach.
They provide on site health services, one–to–one counseling, as well as social activities such as
make–up, sports and cooking. Referrals can be made to transgender–friendly providers of
medical services. One of Sisters goals is to foster public support and greater acceptance of the
transgender community in Pattaya. This remains a challenge. Currently, Sisters DiC has over 700
members.
Establishment of ‘in–house’ counseling and VCT services since 2006
In collaboration with the Department of Health Promotion, Banglamung Hospital, Pattaya, Sisters
DiC began providing counseling and VCT services in 2006. A TG nurse from Banglamung
Hospital comes to the drop–in center for four sessions per week to provide VCT. PSI should be
applauded for the successful partnership with the hospital. Sisters DiC is also one of the sites
selected for the community–based VCT rapid testing pilot project under the Global Fund Round 8
grant.
Significant success in reaching hard to reach populations — TG sex workers
Peer educators, working though the Sisters DiC, are successful in reaching TG sex workers at
three types of locations; at targeted bars/hotspots, during home visits to TG ,and at the Sisters
DiC. Sisters recognizes that while successful in reaching TG, the behavior change process requires
a long–term commitment, with frequent visits and ‘after–service’ contact.
Sisters PE indicated that while the situation has improved, there still remains occasional
interference with their work from law enforcement authorities. However, government health
authorities recognize the value of the Sisters PE HIV awareness and prevention efforts.  
PSI/Sisters involves MARPs in developing behavior change strategies, messages and materials
PSI/Sisters place emphasis on including TG in the design and delivery of BCC interventions and
resources. TG peer educators are skilled in leading prevention activities among beneficiaries.
Sisters involvement of TG in PE activities helps to ensure TG access to VCT services.
PSI/Sisters has contributed to improved access and availability of HIV/STI preventive
products (condoms, lube) for MARPs to these preventive products
Distribution of branded condoms and lubricants are an essential part of Sisters peer education
and outreach activities. This includes demonstrations/training in correct condom use.
67
68
6.3.3 Strengths and facilitating factors
Strengths and facilitating factors include:
• A dedicated and skilled group of peer educators working both in outreach and drop–in
center activities.
• A strong, supportive relationship with government health services (Banglamung Hospital,
Pattaya) allowing for MARP–friendly clinical services at the drop–in center.
• Involvement of TG in the development of IEC interventions and resources.
6.3.4 Challenges and barriers
• Condom use by IDU and FSW with regular partners is very low (although there is no issue
with availability of quality condoms).
• TG are reluctant to approach their regular partners about condom use. Attitude change will
require a significant and sustained IPC approach.
• Stigma and discrimination towards TG is still considerable. Addressing this will require the
creative and sustained efforts focusing on the ‘general population’ and law enforcement
authorities.
• Maintaining contact with migrant TG (Thai, Vietnamese, Khmer and Lao) is an issue.
Innovative approaches and resources to maintain meaningful, influential contact with
migrant TG need to be considered.
• Behavior change is a long–term process. Sisters PE must spend considerable time in carrying
out outreach activities to ensure solid change.
• Although TG have unique needs and concerns (such as hormonal issues), TG are often
grouped with broader MSM programming which may not address TG specific issues. There
is a need to develop TG specific BCC resources and approaches to respond to their distinct
and unique needs.
• Due to budget constraints, PSI/Sisters has been unable to implement the TRaC
methodology for the TG program. In order to measure effectiveness of the current
interventions, adjust program needs, and contribute to the documentation and
replication of the model, it is important that the USG or other funds be found to
implement TRaC.
6.3.5 Replication and sustainability
The Sisters DiC is strong, both from a management and programmatic sense. The center is well
organized, has strong and supportive linkages with government partners and has an active in–
house activity and outreach program for the TG community in Pattaya. Sisters are acknowledged
as being innovative and successful in reaching out to and organizing the TG community in
Pattaya, including both Thai and non–Thai TG. This model should be fully documented and
considered for replication in other areas of Thailand and regionally.  
Procurement Sensitive
7. Future Directions (THIS SECTION HAS BEEN REMOVED PER 
ROP) 
PSI interventions in Burma, China, Lao and Thailand display a high level of performance, with
strong progress to date. The progress is even more impressive given the political and social
constraints faced in these countries. The rate of progress for interventions contributing to HIV
and AIDS prevention is impressive. Nevertheless, a number of challenges remain which must be
taken into consideration when planning for further USAID inputs to Burma, China, Lao and
Thailand.
This section puts forward recommendations for future directions by USAID organized by 1)
prevention, 2) strategic information and 3) program management per country as well as
suggesting regional needs.
69
Annex 1: Key documents reviewed
PSI Burma
1. Social Marketing for STI/HIV Prevention Among High–Risk Groups in Burma,
Implementation Plan, Year 1 (1 October 2007–30 September 2008), November 2007
2. Social Marketing for STI/HIV Prevention Among High–Risk Groups in Burma,
Implementation Plan, Year 2 (1 October 2008–30 September 2009), July 2008
3. Social Marketing for STI/HIV Prevention Among High–Risk Groups in Burma,
Implementation Plans for PSI/China, PSI/Laos/ & PSI/Burma (combined), Year 3 (1 October
2009–30 September 2010), July 2009
4. Population Services International: Burma — Annual Report FY2007
5. Population Services International: Burma — Annual Report FY2008
6. Population Services International: Burma — Annual Report FY2009
7. Social Marketing for STI/HIV Prevention Among High–Risk Groups in Burma, China, Laos,
and Thailand – Proposal for Cost Extension (1 October 2007–30 September 2010), revised July
2007
8. National AIDS Program – National Strategic Plan for HIV and AIDS in Myanmar Progress
Report 2008
9. National AIDS Program, Department of Health, Ministry of Health – Report of the HIV
Sentinel Sero‐Surveillance Survey Myanmar 2008
10. Myanmar (2008): HIV/AIDS TRaC Among Female Sex Workers; First Round
11. Myanmar (2008): HIV/AIDS TRaC Among Clients of Female Sex Workers; First Round
12. Myanmar (August 2009): MAP – Measuring Access and Performance Study Round 2 –
Coverage and quality of male condoms in Myanmar
13. Myanmar (2008): HIV/AIDS TRaC Among Men Who Have Sex with Men; First Round
PSI China
1. Social Marketing for STI/HIV Prevention Among High–Risk Groups in P.R. China,
Implementation Plan, Year 1 (1 October 2007–30 September 2008), November 2007
2. Social Marketing for STI/HIV Prevention Among High–Risk Groups in P.R. China,
Implementation Plan, Year 2 (1 October 2008–30 September 2009), July 2008
3. PSI/China Huxianghao Program (PSI fact sheet)
4. Mengzi Sisterhood Health Home—targeted HIV/AIDS prevention intervention (PSI fact sheet)
5. Integrated CA Support to Build Community Capacity: The Case of Kang Xin Homeland (PSI
Fact sheet)
6. PSI/China Capacity Building Program: Launching Community–based Detoxification and
Rehabilitation in Yunnan and Guangxi
7. Population Services International: China — Annual Report FY 2007
8. Population Services International: China — Annual Report FY 2008
9. Routine Behavioral Tracking (RBT) Implementation Plan: FSW & MSM Programs in Yunnan
and Guangxi (as of September 10, 2009).
10. Introduction to Routine Behavioral Tracking (RBT) Surveys: September 23, 2009
11. PSI China FSW TRaC Report August 2005
12. PSI China FSW TRaC Report December 2006
13. PSI China FSW TRaC Report December 2008
14. PSI China IDU TRaC Report February 2006
15. PSI China IDU TRaC Report 2009 Draft
70
16. PSI China M&E Framework 2008  
PSI Lao
1. Social Marketing for STI/HIV Prevention Among High–Risk Groups in the Lao PDR,
Implementation Plan, Year 1 (1 October 2007–30 September 2008), November 2007
2. Social Marketing for STI/HIV Prevention Among High–Risk Groups in the Lao PDR,
Implementation Plan, Year 2 (1 October 2008–30 September 2009), July 2008
3. Social Marketing for STI/HIV Prevention Among High–Risk Groups in Burma,
Implementation Plans for PSI/China, PSI/Laos/ & PSI/Burma (combined), Year 3 (1 October
2009–30 September 2010), July 2009
4. Population Services International: Laos — Annual Report FY2007
5. Population Services International: Laos — Annual Report FY2008
6. Population Services International: Laos — Annual Report FY2009
7. Laos (July 2009): MAP – Measuring Access and Performance Study Evaluating the
Availability of Number One Condoms and One Stop Kit; Round 1
8. Laos (2008): HIV Prevention TRaC Study Among Lao Female Sex Workers; Second Round
9. PSI/Laos: Research Brief (2008) – HIV Prevention Programming among Transgenders: Lessons
from Laos
10. Laos (2009): First Round HIV/STI Prevalence and Third Round TRaC Survey Among Male‐to‐
Female Transgenders in Vientiane Capital and Savannakhet, Lao PRD (TRaC Study Design
proposal submitted to CHAS 15 October 2009)
11. UN Draft Document: Health Financing Strategy 01‐05‐2010  
12. Draft Report: External Review of the 100% Condom Use Programme and Sexually
Transmitted Infection Services in Selected Sites in Lao People’s Democratic Republic (June
2009)
PSI Thailand
1. Population Services International: Thailand — Annual Report FY 2007
PSI Regional
1. Social Marketing for STI/HIV Prevention Among High–Risk Groups in the Mekong Region,
Implementation Plans, China, Laos, Burma; Year 3 (1 October 2009–30 September 2008),
November 2010
2. Social Marketing for STI/HIV Prevention Among High–Risk Groups in the Mekong Region,
China, Laos, Burma Annual Report FY 2009; October 2009
3. Social Marketing and Targeted Communications for HIV/AIDS Prevention Among Most‐at‐
Risk Populations in Burma, China, Laos, and Thailand; Proposal for Cost Extension Revised
July 2007.
USAID
1. Review of the Minimum Package of Services for Most At–Risk Populations, USAID/RDMA,
June 2009
2. Review of the Supportive Interventions Components of USAID’s Comprehensive Prevention
Package for Most at Risk Populations in China, Draft Report, December 2009
71
Annex 2: Site visits/organizations visited 
Burma
Organization Location
PSI Senior Management, PSI Burma Headquarters Rangoon
PSI TOP Program Management Rangoon
PSI TB Program Management Rangoon
International HIV/AIDS Alliance and partners Rangoon & Mandalay
National AIDS Program, Ministry of Health Rangoon
PSI TOP Program FSW and MSM outreach sites Rangoon
Pact staff Rangoon
UNAIDS/Myanmar Rangoon
PSI TOP Drop‐in Center Lashio
Asian Harm Reduction Network Drop‐in Center Lashio
PSI Drop‐in Center Mandalay
PSI QC Center Mandalay
Local Department of Health Mandalay
China
Organization Location
Guangxi Prevention and Treatment of HIV/AIDS Committee Office Nanning
Nanning Narcotics Control Committee Office Nanning
Wangzhou Community Detoxification and Rehabilitation Center/Management Nanning
Hengyang MMT Clinic Nanning
Medecins sans Frontieres   Nanning
Luzhai CDC Luzhai
Red Ribbon Center Luzhai
Shangyi Community Center Kunming
PSI staff/PSI office Kunming
Yunnan Institute for Drug Abuse Kunming
Huxianghao Ba Drop–in Center (MMT provision) Kunming
PSI staff/PSI office Kunming
Huxianghao Ba Drop–in Center (Peer Educators) Kunming
Huxianghao Ba Drop–in Center (Beneficiaries) Kunming
Mile Public Health Bureau, AIDS Office Mile
Honghe Brothers Center Mile
Sisterhood Health Home (MCH doctor) Mengzi
Mengzi CDC Mengzi
Mengzi County Public Health Bureau, AIDS Office Mengzi
Sisterhood Health Home (Beneficiaries) Mengzi
Sisterhood Health Home (Peer Educators) Mengzi
72
Organization Location
Honghe Prefecture CDC Mengzi
Kangxin Home Mengzi
Green Garden Community Center Gejiu
Lao
Organization Location
PSI managers and staff, PSI Headquarters Vientiane
FHI FSW DiC Vientiane
FHI managers and staff Vientiane
Burnet Institute Vientiane
Ministry of Health/Centre for HIV, AIDS and STIs Vientiane
WHO Vientiane
UNAIDS Vientiane
PSI New Friends DiC Vientiane
Retail pharmacies Vientiane
Guest houses Vientiane
PSI New Friends DiC Luang Prabang
Provincial Coordinating Committee for AIDS Luang Prabang
Thailand
Organization Location
SWING Pattaya
Sisters Pattaya
USAID/RDMA regional partners
Organization Location
Health Policy Initiative Bangkok (via phone)
Family Health International Asia Pacific Regional Office (FHI/APRO) Bangkok; China (via phone)
Pact Bangkok
73
Annex 3: Map of current locations of the TOP program (Burma) 
74
Annex 4: PSI/Burma TOP activity data 
This Annex provides more detailed data in relation to PSI/Burma’s Targeted Outreach Program. An 
overview of this data is provided in 3.3.2 in the main section of the report. 
TOP outreach activity levels: MSM 28 
Table 6: TOP MSM outreach contacts: 2007–2009
Year New individual
MSM contacted
% increase
previous year
Repeat MSM
contacts*
% increase
previous year
Total MSM
contacts#
% increase
previous year
2007 38,629 – 61,488 – 100,117 25
2008 47,562 23 77,353 26 124,915 25
2009 46,187 – 3 101,248 31 147,435 18
Total 132,378 240,089 372,467
*  Repeat MSM contacts is the total number of outreach contacts with previously reached MSM. It is not
individual MSM and includes repeat contacts with the same MSM. # Total MSM contacts is the total of new
individual contacts, plus repeat MSM contacts. Source: PSI Burma.  
TOP outreach activity levels: FSW 
Table 7: TOP FSW outreach contacts: 2007–2009
Year New individual
FSW contacted
% increase
previous year
Repeat FSW
contacts*
% increase
previous year
Total FSW
contacts*
% increase
previous year
2007 33,239 – 56,229 – 89,468 33
2008 30,065 – 10 67,231 20 97,296 9
2009 33,884 13 96,442 43 130,306 34
Total 97,188 219,902 317,070
*  Repeat FSW contacts is the total number of outreach contacts with previously reached FSW. It is not individual
FSW and includes repeat contacts with the same FSW. # Total FSW contacts is the total of new individual
contacts, plus repeat FSW contacts. Source: PSI Burma.
TOP DiC activity levels: MSM
Table 8: TOP MSM DiC visits: 2007–2009
Year
New
individual
MSM DiC
members
%
increase
previous
year
Total
individual
MSM DiC
visits
%
increase
previous
year
Total MSM
DiC visits*
% increase
previous year
Average No.
DiC
visits/MSM
member#
2007 7,038 – 10,201 – 54,015 – 5.3
2008 9,013 28 13,555 33 63,137 17 4.7
2009 13,045 45 19,621 45 98,137 56 5.0
Total 29,096 43,377 215,289
*  Total visits; not individuals. # This data shows the average number of DiC visits per year for members who
visited in that year but does include MSM members who registered in a previous year but did not visit in that
year. Source: PSI Burma.
                                                      28 Activity data is for the calendar years 2007–2009. USAID funding of PSI’s activities under the
existing contract extension commenced in October 2007. Accordingly, the 2007 data can primarily
be regarded as baseline data for this contract.
75
TOP DiC activity levels: FSW
Table 9: TOP FSW DiC visits: 2007–2009
Year
New
individual
FSW DiC
members
% increase
previous
year
Total
individual
FSW DiC
visits
% increase
previous
year
Total
FSW DiC
visits*
% increase
previous
year
Average No.
DiC
visits/FSW
member#
2007 5,938 – 8,504 – 48,070 – 5.7
2008 6,749 14 10,302 21 49,303 3 4.8
2009 9,874 32 15,936 54 81,414 65 5.1
Total 22,561 34,742 178,787
*  Total visits; not individuals. # This data shows the average number of DiC visits per year for members who
visited in that year but does include FSW members who registered in a previous year but did not visit in that
year. Source: PSI Burma.
STI clinical services: MSM
Table 10: STI consultations and treatment at TOP DiCs for MSM: 2007–2009
Year STI consultation and
Treatment
% increase on
previous year
% of individual MSM attending DiCs who
went to STI clinic
2007 3,972 – 39
2008 6,145 55 45
2009 8,749 42 45
Total 18,866
Source: PSI Burma
STI clinical services: FSW
Table 11: STI consultations and treatment at TOP DiCs for FSW: 2007–2009
Year STI consultation and
Treatment
% increase on
previous year
% of individual FSW attending DiCs who went
to STI clinic
2007 4,948 – 58
2008 6,204 25 60
2009 9,153 48 57
Total 20,305
Source: PSI Burma
VCT services: MSM
Table 12: VCT at TOP DiCs for MSM: 2007–2009
Year MSM having
VCT
% increase on
previous year
% with HIV +
results
% of individual MSM attending DiCs
who had VCT
2007 1,520 – 16 15
2008 2,342 54 17 17
2009 2,514 7 11 13
Total 6,376
Source: PSI Burma
76
VCT services: FSW
Table 13: VCT at TOP DiCs for FSW: 2007–2009
Year FSW having
VCT
% increase on
previous year
% with HIV +
results
% of individual FSW attending DiCs
who had VCT
2007 2,022 – 19 24
2008 2,212 9 18 21
2009 2,664 20 17 17
Total 6,898
Source: PSI Burma
77
Annex 5: Strategic information activities for PSI/Burma and PSI Lao 
PSI/Burma  
The following strategic information activities were included in PSI/Burma’s annual work plans
for the period 2007‐2010. Section 3.4 contains an analysis of these activities.  
Year 1: 2007‐08
 Conduct annual TRaC survey (FSW, clients of FSW, and MSM) in Rangoon, Mandalay, Lashio,
Myitkyina, and additional intervention area(s) as appropriate
 Conduct Project MAP (Measuring Access and Performance) survey to track product
availability in all project sites
 MIS (monthly monitoring report)
Year 2: 2008‐09
 Conduct annual TRaC survey (FSW, clients of FSW, and MSM) in Rangoon, Mandalay, Lashio,
Myitkyina, and additional intervention area(s) as appropriate
 Conduct Project MAP (Measuring Access and Performance) survey to track product
availability in all project sites
 MIS (monthly monitoring report)
Year 3: 2009‐10
 Conduct annual TRaC–M survey (3 surveys in 2009 focused on FSW, clients of FSW, and
MSM)
 Conduct Project MAP (Measuring Access and Performance) survey to track product
availability in all project sites for MSM and FSW
 MIS (monthly monitoring report)
 Qualitative survey on determinants on behavior for IDU (funded by BMGF)
 Feasibility assessment on social marketing of clean needles and syringes
PSI/Lao  
The following strategic information activities were included in PSI/Lao’s annual work plans for
the period 2007‐2010. Section 5.4 contains an analysis of these activities.  
Year 1:  
 Conduct follow–up TRaC survey for MSM in Vientiane, Savannakhet, and Luang Prabang
 Conduct Project MAP (Measuring Access and Performance) survey to track condom
availability in all four target sites
 Analyze data from surveys
 Disseminate survey results to relevant national and local governmental organizations, NGOs,
and international partners
 Train partners and other organizations to read and understand survey information
Year 2:
 Conduct follow–up TRaC survey for MSM in Vientiane, Savannakhet, and Luang Prabang
 Conduct Project MAP (Measuring Access and Performance) survey to track condom
availability in all four target sites
 Analyze data from surveys
78
 Disseminate survey results to relevant national and local governmental organizations, NGOs,
and international partners
 Train partners and other organizations to read and understand survey information
Year 3:
 Conduct follow–up TRaC survey for FSW in Vientiane, Savannakhet, Champasak, and Luang
Prabang
 Conduct follow–up TRaC survey for MSM in Vientiane, Savannakhet, and Luang Prabang
 Conduct Project MAP (Measuring Access and Performance) survey to track condom
availability in all four target sites
 Analyze data from surveys
 Disseminate survey results to relevant national and local governmental organizations, NGOs,
and international partners
 Train partners and other organizations to read and understand survey information
79
Annex 6: PSI results by PEPFAR core indicators and project objectives 
This annex presents data provided by PSI through the USAID PEPFAR annual reporting
requirement in FY07–09. PSI is required to report annually to USAID using the PEPFAR “core
indicators”, listed below in italics. The “Project Objectives” are those that were listed in PSI’s
Mekong Regional Cost Extension Proposal and contribute to USAIDR/RDMA’s HIV and AIDS
strategy. The first year of PSI’s Mekong Regional Cost Extension Proposal was FY08 (October 1,
2007). FY07 data under the previous PSI agreement is also provided to serve as a baseline. FY10
data will be available upon completion of this project in October 2010. Below is a list of
limitations regarding the data presented below:  
 All targets and results below are highly variable as the PEPFAR definitions of target setting
and indicators changed from year to year. This makes it difficult to compare the results over
the years; however progress has been achieved over the life of the project as has been
described in each of the country chapters in the report.
 Useful quantitative information is not available for the project objectives of: increased access
to strategic information and strengthened the enabling environment. This is because the
PEPFAR indicator in this area includes only number of people of trained, which does not
accurately capture meaningful progress toward this project objective. Qualitative progress
made by PSI toward these important two objectives has been described in each of the country
chapters in the report.
 The target set for prevention in Burma in FY08 are quite high as “migrant populations” were
included as a MARP in the target setting calculation as well as in the results. This was re–
adjusted in the calculation in FY09, resulting in a large variance from FY07–FY09.
 Care and treatment results (palliative care and ART indicators) for Burma in FY08 were not
realized as a pilot project was initially included in targeting setting, but not implemented due
to programmatic shifts that were made in consultation with USAID.
 Treatment targets and indicators for Burma include “indirect” support through other donors
such as 3D Fund and MSF.
 There are no care results for PSI/Lao as the care elements of their program, namely, VCT,
began in FY2010.
 As noted in the Thailand chapter of the report, USAID support to PSI/Thailand ended after
FY07 therefore there are no results are presented after this time. These results still collected by
USAID through the support to Pact and FHI for PSI/Sisters.
A. PSI/Burma
Project Objective FY07 FY08 FY09
Target Result Target Result Target Result
Increased access to prevention interventions
for MARPs
Number of individuals reached through
community outreach with promote HIV and AIDS
prevention through other prevention
200 250 475000 319323 225000 161682
Increased access to care, support, and
treatment for PLHA
Number of individuals who received counseling
and testing for HIV and received their test results
(ALL including TB patients VCT)
– – 7550 9441 10050 11965
80
81
Project Objective FY07 FY08 FY09
Target Result Target Result Target Result
Number of individuals provided with HIV–related
palliative (including TB/HIV)
37 33 50 0 0 429
Number of individuals receiving antiretroviral
therapy
– – 50 0 50 48
B. PSI/China
Project Objective FY07 FY08 FY09
Target Result Target Result Target Result
Increased access to prevention interventions
for MARPs
Number of individuals reached through
community outreach with promote HIV and AIDS
prevention through other prevention
350 847 34000 24950 16174 25451
Increased access to care, support, and
treatment for PLHA
Number of individuals who received counseling
and testing for HIV and received their test results
(ALL including TB patients VCT)
– – 120 344 170 291
C. PSI/Lao
Project Objective FY07 FY08 FY09
Target Result   Target Result   Target Result
Increased access to prevention interventions
for MARPs
Number of individuals reached through
community outreach with promote HIV and AIDS
prevention through other prevention
2700 2322 21300 20996 23200 25997
D. PSI/Thailand
Project Objective FY07 FY08 FY09
Target Result   Target Result   Target Result
Increased access to prevention interventions
for MARPs
Number of individuals reached through
community outreach with promote HIV and AIDS
prevention through other prevention
290 115 – – – –