42179-013: Consultant's Report

Technical Assistance Consultant’s Report

Project Number: 42179-013 February 2015

Regional: Greater Mekong Subregion Capacity Building for HIV/AIDS Prevention Project (Financed by the Cooperation Fund for Fighting HIV/AIDS in Asia and the Pacific)

Prepared by: TA 8204 Consultants

(led by Scott Bamber with contributions from Lao PDR and Viet Nam

national consultants)

For: Asian Development Bank

This consultant’s report does not necessarily reflect the views of ADB or the Government concerned, and ADB and the Government cannot be held liable for its contents. (For project preparatory technical assistance: All the views expressed herein may not be incorporated into the proposed project’s design.

RETA-8204 (REG): Regional Capacity Development Technical Assistance for Greater Mekong Subregion Capacity Building for HIV/AIDS Prevention

Completion Report April 2013 - December 2014

Asian Development Bank Submitted December 2014

Table of Contents

Table of Contents ...... 2 Acronyms and abbreviations ...... 3 Map of Lao PDR and Viet Nam border provinces ...... 4 1. Introduction ...... 5 1.1 Background ...... 5 1.2 Brief description of TA 8204 ...... 6 2. Project Accomplishments (against deliverables) ...... 6 2.1 Output 1: Enhanced capacity for regional planning and management of HIV programs ...... 6 2.2 Output 2: Improved access to and quality of HIV services for migrants and mobile populations at border provinces ...... 8 2.3 Output 3: Shared knowledge product on regional cooperation on HIV and AIDS prevention and management ...... 10 2.4 Additional assistance provided to the grant and loan projects and national responses in Lao PDR and Viet Nam ...... 12 3. Monitoring and Evaluation activities ...... 12 4. Key Challenges and Lessons Learned ...... 13 5. Sustainability and Transition Planning ...... 15 7. Annexes ...... 17

Acronyms and abbreviations

ADB Asian Development Bank AIDS Acquired immune-deficiency syndrome APF Advance Payment Facility ART Anti-retroviral therapy ARV Anti-retroviral drug CDC2 Second Greater Mekong Subregion Regional Communicable Disease Control Project 2011-2015 CHAS Centre for HIV and AIDS and STI EA Executing Agency GF Global Fund for AIDS, TB and Malaria GMS Greater Mekong Subregion HAARP HIV/AIDS Asia Regional Programme (Australian Aid) HIV Human immuno-deficiency virus HR Harm Reduction IA Implementing Agency ICAAP International Conference on AIDS in Asia and the Pacific JAP Joint Action Plan KAP Key affected populations KP Knowledge product LNP+ Lao Network of People Living with HIV M&E Monitoring and evaluation MOU Memorandum of Understanding MSM Men who have sex with men NGO Non-Government Organization NSAP National Strategic Action Plan NSP Needle and syringe programme PAM Project Administration Manual PAC Provincial AIDS Centre PCCA Provincial Centre for Control of AIDS PMU Project Management Unit POC Point of care PWID People who inject drugs RCTA Regional Chief Technical Advisor RSC Regional Steering Committee STI Sexually-transmitted infection TA Technical Assistance TOR Terms of Reference UNAIDS Joint United Nations Program on HIV and AIDS VAAC Viet Nam Administration of HIV/AIDS Control VCT Voluntary counseling and testing WHO World Health Organization

Map of Lao PDR and Viet Nam border provinces

1. Introduction

1.1 Background The Asian Development Bank (ADB) approved L2930-VIE/G0312-LAO: Greater Mekong Subregion (GMS) Capacity Building for HIV/AIDS Prevention Project (the Project) with a grant of $5 million to the Government of Lao PDR and a loan of $15 million to the Government of Viet Nam on 30 October 2012. Project outputs are (i) strengthened planning and management capacity, (ii) enhanced capacity to provide quality and accessible services, (iii) improved access to HIV prevention outreach among target populations, and (iv) effective and sustainable regional collaboration to strengthen HIV response. In Lao PDR, the grant became effective on 8 February 2013 and will be implemented over 5 years with a physical completion date of 31 December 2017 and a grant closing date of 30 June 2018.1 In Viet Nam, the loan became effective on 7 May 2013 and will be implemented over 5 years with a loan closing date of 30 June 2018.2 The Project has a piggy-backed TA (TA8204) on Regional Capacity Development for Strengthened HIV Response with a grant amount of $1 million funded by the Cooperation Fund for Fighting HIV/AIDS in Asia and the Pacific3, which was approved on 30 October 2012. The TA was implemented over 20 months to support the implementation of the Project and will close on 31 December 2014. The purpose of the TA is to support HIV service delivery for migrants and mobile populations in high-risk settings at cross-border areas in Lao PDR and Viet Nam, in particular Output 4 of the Project, which focuses on prevention of HIV in cross-border settings. The TA consultants comprised i) a regional technical advisor (RCTA); ii) a national program coordinator (Viet Nam); and iii) a national program coordinator (Lao PDR). The TA also engaged six national consultants (three in Viet Nam and three in Lao PDR) to develop and implement pilot service delivery under Output 2 of the TA project. Recruitment began in March 2013, with appointment of the international Regional Technical Advisor and national Program Coordinators for Lao PDR and Viet Nam in April 2013. The six national consultants were recruited in July 2014. From the commencement of the Project until completion, the following TA 8204 consultants were recruited: Table: 1 TA team Name Engaged since Regional Technical Advisor Scott Bamber 21 April 2013 Program Coordinator (Viet Nam) Hien Nguyen (resigned June 2013) 4 April 2013 Program Coordinator (Viet Nam) Nguyen Kieu Trinh (replaced Hien 7 August 2013 Nguyen) Program Coordinator (Lao PDR) Phet Viphonhien (resigned 15 18 April 2013 November 2013) Program Coordinator (Lao PDR) Souphom Saysithidej (replaced Phet 23 June 2014 Viphonhien) National consultants for pilot proposal development (6) Lao PDR (3) Finance and Administrative Ms. Phuangphanh Keovanthong 4 July 2014 Technical Dr. Manivone Thikeo 21 July 2014 Technical Mr. Khampone Vichittavong 31 July 2014 Viet Nam (3) Finance and Administrative Ms. Trinh Thi Hang 8 July 2014 Technical Dr. Chu Quoc An 30 July 2014 Technical Dr. Do Viet Dung 4 July 2014

1 The project includes 8 provinces in the Lao PDR (Attapeu, Bokeo, Champasak, Houaphanh, Louang Namtha, Oudomxay, Phongsaly, and Salavanh) 2 The project includes 15 provinces in Viet Nam (Ha Giang, Lao Cai, Lai Chau, Dien Bien, Son La, Thanh Hoa, Ha Tinh, Quang Binh, Quang Tri, Quang Nam, Kon Tum, Gia Lai, Dak Nong, Binh Phuoc, Long An). 3 Contributor: the Government of Sweden. 5

Inception Missions were undertaken in Viet Nam from 10–16 June, and in Lao PDR from 17–20 June 2013, by a team comprising ADB Manila-based staff, project consultants and TA team members under leadership of the ADB Sr. Project Health Specialist. The project Inception Report was completed in September 2013.

1.2 Brief description of TA 8204 Project impact Enhanced regional HIV response system. Project outcome Improved HIV and AIDS prevention and management at cross-border provinces in Lao PDR and Viet Nam. Project timeframe The timeframe for TA 8204 was 20 months, with the project inception in April 2013 and completion in December 2014. Inception Missions were fielded to Ha Noi and Vientiane in June 2013, and a Final Consultation Mission held in Lao PDR in the period 8-12 December 2014. Project outputs The TA has three outputs: i) Capacity building for regional planning and management of HIV programs; ii) Pilot-testing of service delivery models for improved access to and quality of HIV services for migrants and mobile populations at border areas; iii) Shared knowledge on regional cooperation on HIV prevention and management. This report outlines project activities and achievements in line with these three outputs. The report also discusses the key challenges faced encountered during the course of the project, and makes recommendations relating to the sustainability of the project outcomes and implementation of similar initiatives elsewhere in the GMS region and beyond. 2. Project Accomplishment Progress to the end of December 2014 against the TA 8204 Key Project Deliverables is summarized in Annex 1. The key project accomplishments, by output, are as follows:

2.1 Output 1: Enhanced capacity for regional planning and management of HIV programs This output supported initiatives to improve capacity for regional cooperation in HIV prevention and control, mainly by helping establish regional cross-border cooperation mechanisms operating at the national and cross-border provincial level. Key activities under this output consisted of completion of a review of existing agreements and MOUs for cross-border cooperation on HIV and AIDS between Viet Nam and Lao PDR, at the national and provincial level, and the development of new MOUs, together with Joint Action Plans (JAPs) covering the period 2014–2017. Three MOUs were signed and one MOU ratified:  CHAS-VAAC (30th September 2014)  Kontum-Attapeu (12th March 2014  Houaphanh-Thanh Hoa-Son La (22nd May 2014  Phongsaly-Dien Bien (11-12th June 2014; ratified existing agreement of November 2013) Four JAPs were prepared, between:  CHAS-VAAC  Kontum-Attapeu

 Houaphanh-Thanh Hoa-Son La  Phongsaly-Dien Bien Key activities included in the MOUs and JAPs consisted of: regular sharing and exchange of information between CHAS and VAAC, including annual meetings; training; provision of resource persons; site visits; access to VCT and ARV services for border populations; and joint planning and development of program activities. In addition, under this output, a situational assessment of TA target provinces was conducted to generate profiles of each province. The provincial profiles summarize key information on each province relevant to the planning of workshops, meetings and capacity building activities implemented under the TA 8204 project, as well as the identification of target populations and HIV prevention activities for the pilot projects designed by national consultants. In addition, the profiles will contribute important background information, on the cross-border situation, and migrant and mobile populations, to the baseline data for the grant and loan projects in Lao PDR and Viet Nam. Table 2: Summary of achievements against selected deliverables for Output 1

Output Selected Indicators Key Deliverables Achievements Output 1: Framework for regional Provincial situational  Profiles of all seven border target Enhanced cross-border HIV and analysis/profile provinces completed and summarized in capacity for AIDS responses report, covering, including situation of HIV regional planning between Lao PDR and and AIDS and migration, capacity for, and and management Viet Nam established in experience in, cross-border HIV and AIDS of HIV programs. all TA provinces. prevention activities. Review and assessment  Review and assessment completed of of regional covenants, regional covenants, joint initiatives, and joint initiatives, and policies on HIV and AIDS prevention in policies on HIV and AIDS cross-border settings: initial reviews. prevention in cross-border Results presented at HIV and AIDS settings Workshop at Regional Steering Committee, Siem Reap, September 2013 and Viet Nam National Scientific Conference on HIV and AIDS, 2 Dec 2014, and final version at Bilateral Meeting on Cross-Border Collaboration on HIV and AIDS, Ha Noi, 30 September-1 October 2014. One national level MOU,  National level MOU signed between CHAS and provincial MOUs and VAAC signed on 30th September signed between two pairs 2014; of target provinces, and existing MOU for one  Provincial MOU between Kontum and th provincial pair reviewed. Attapeu signed on 12 March 2014;  Provincial MOU between Houaphanh and Thanh Hoa and Son La signed on 22nd May 2014;  Existing MOU of November 2013 between Phongsaly and Dien Bien reviewed and ratified on 11-12th June 2014. 5-year strategic plan Five-year strategic plans  National level JAP between CHAS and developed and (Joint Action Plans) VAAC prepared 1st October 2014; implemented (2013- identifying key areas for 2017) cross-border cooperation  Provincial JAP between Kontum and and coordination for Attapeu drafted on 12th March and national level and three finalized on 1st October 2014;

Output Selected Indicators Key Deliverables Achievements provincial cross-border target province pairs  Provincial JAP between Houaphanh and Thanh Hoa and Son La drafted 21-22 May and finalised 1st October 2014;  Provincial JAP between Phongsaly and Dien Bien, drafted 11-12th June and finalized 1st October 2014; Annual workplans Annual workplans for  Not completed because planned TA wrap- developed and national level and three up transition meeting was not approved by implemented by provincial cross-border ADB for implementation as planned provincial HIV target province pairs committees during the two-year project period

2.2 Output 2: Improved access to and quality of HIV services for migrants and mobile populations at border provinces Under this output, pilot interventions were conducted to provide HIV and AIDS outreach and services for migrants and mobile populations and key populations in high-risk settings. In Lao PDR, pilot project proposals were developed and implemented in three provinces:  Attapeu  Houaphanh  Phongsaly The proposals were developed by provincial HIV and AIDS personnel, with support from TA consultants and CHAS, and included three-year workplans, with a view to providing, for successful interventions, a smooth transition to continued funding under grant project’s block grant mechanism: In Lao PDR, two models were developed, one, in Attapeu province, and the other covering Houaphanh and Phongsaly provinces. The Attapeu project focuses on strengthening HIV prevention among migrant workers in the province, in particular Vietnamese and Lao workers, together with sex workers in nearby towns and settlements, as well as owners or management of private enterprises. The Attapeu project is the first time that HIV prevention among Vietnamese migrant workers has been addressed in a specific program in Lao PDR. The project includes advocacy activities, to engage the private sector through collaboration with big private enterprises, such as Hoang Anh Gia Lai (HAGL), Song Da and other companies, which employ large numbers of migrant workers. The Houaphanh and Phongsaly projects built on activities previously supported under the Australian Government’s discontinued HAARP project, to strengthen the needle and syringe program (NSP) for prevention of HIV among people who inject drugs (PWID) and establishment of a point of care (POC) system, for increased access to VCT, and to ARVs, for those who were tested positive. The Houaphanh and Phongsaly projects are important because, apart from being the only harm reduction program with people who inject drugs in Lao PDR, they are now being implemented under CHAS, rather than the Lao Committee for Drug Control (LCDC). The pilot projects in the three provinces have been documented for sharing of the approaches and lessons learned. In Viet Nam, pilot project proposals were developed in four provinces:  Kontum  Thanh Hoa  Son La  Dien Bien

These proposals are based on three models: i) community-based behavior change communication for HIV prevention at border areas where there is no international check point (in some districts of Thanh Hoa and Kontum); ii) border health quarantine-based behavior change communication for HIV prevention at international check points (in Thanh Hoa and Kon Tum); and iii) community-based behavior change communication for HIV prevention adjacent to international check points where a border health quarantine unit is not available (Dien Bien and Son La). Unfortunately, following completion of project proposals, the IA, VAAC, for reason of the limited time remaining for implementation, decided not to proceed with implementation of the pilot project activities. In Lao PDR, an advance payment facility was established for the TA Project for the purpose of funding the pilot activities for Attapeu, Houaphanh, and Phongsaly. A cash advance of USD 46,763, representing 50% of the total approved estimated budget (USD 93,526) for all the pilot activities, was remitted by ADB on 4 November 2014. This amount was divided as follows: $12,240.79 for Attapeu, $21,961.16 for Houaphanh, $5,879.23 for Phongsaly, and the remaining $7,181.82 was kept in PMU’s account to pay for costs of meetings/training/workshops to be held in Vientiane. The PMU agreed to consider the short-term hire of a Finance and Administrative Consultant by the grant project to help follow-up on liquidations, as approved during the September 2014 review mission. Table 3: Results of Pilot Activities, Attapeu province, from November - 19th December 2014

No. participants Place Activities Lao Vietnamese All Advocacy meeting with key stakeholders at provincial 1 Attapeu province 34 1 35 and district level Advocacy meeting for Lao-Vietnamese owners of 2 Attapeu province 27 0 27 entertainment venues HIV outreach activity for migrant workers at Hoang Anh 3 Attapeu province 37 63 100 Gia Lai rubber plantation Saysettha 4 HIV outreach activity for truck drivers at km 37-52 0 20 20 District HIV outreach activity for Lao-Vietnamese owners of Saysettha 5 10 20 30 entertainment places at Ban Phaosamphanvixay District HIV outreach activity for Lao-Vietnamese migrant 6 Sanxay 0 30 30 workers in vicinity of Sekaman hydropower station HIV outreach activity for sex workers and owners of 7 entertainment places in vicinity of Sekaman hydropower Sanxay 0 16 16 station HIV outreach activity for sex workers at International 8 Phuvong 20 0 20 check point

Total 128 150 278

There were three indicators relevant to this output in the DMF. Achievements for selected key deliverables corresponding to these indicators are summarized in Table 4. Table 4: Summary of achievements against selected deliverables for Output 2

Output Selected Indicators Key Deliverables Achievements Joint collaborative Output 2: Pilot interventions for activities in the border  Priority issues for joint collaboration Improved access outreach and service areas between the two between three sets of target provinces to and quality of provision for migrants and countries identified and identified and documented in JAPs during HIV services for mobile populations and implemented during the three cross-border meetings (see Output 1 migrants and key populations at high two-year project period and Cross-border Meeting Reports for mobile risk settings designed, 9

populations at implemented and Kontum, Houaphanh and Phongsaly); Joint HIV and AIDS border provinces. documented outreach and service  Pilot interventions designed, with a total of provision conducted for 3 models, documented for 4 provinces in at least 50% of targeted Viet Nam (Kontum, Thanh Hoa, Son La migrant and mobile and Dien Bien); populations in two years.  Pilot interventions designed, documented and implemented in 3 provinces in Lao Appropriate modalities PDR (Attapeu, Houaphanh and for cross-border HIV Phongsaly), using two models; prevention and treatment piloted and  Over 278 (150 Vietnamese and 128 Lao) documented in at least migrant workers, entrepreneurs and key 2 of the Lao and 2 of stakeholders participated in activities the Viet Nam target during November-December 2014. provinces

2.3 Output 3: Shared knowledge product on regional cooperation on HIV and AIDS prevention and management This output supported the development of knowledge products culled from the learning and experiences in operating cross-border coordination mechanisms and piloting of appropriate modalities for improved access to and provision of HIV and AIDS information and services for migrants and mobile populations. Knowledge products produced include:  Four reports on cross-border meetings that describe the content of the meetings, types of information exchanged, and agreements on upcoming activities;  Provincial profile report, which summarizes, for the seven target provinces, information on the HIV and AIDS situation, the situation of migrants and mobile populations, cross-border cooperation on HIV and AIDS and provincial capacity to respond to HIV and AIDS. The profiles were intended to support planning of workshops, meetings and capacity building activities to be implemented under the TA 8204, grant and loan projects, and provincial pilot projects. In addition the provincial profiles will contribute to the baseline data for the grant and loan projects in Lao PDR and Viet Nam;  Five case studies of beneficiaries and implementers. These case studies, covering a variety of individuals and processes, will serve to promote awareness and understanding of the HIV and AIDS vulnerabilities of migrants and border communities, as well as documenting the value of capacity-building for HIV and AIDS among provincial and district personnel, and also identification of strengths and areas for improvement in management and administrative frameworks;  Models for the two provincial pilot activities in Lao PDR, and three models in Viet Nam, which were documented for sharing of approaches and lessons learned;  GMS HIV website migrated to CDCII/Health Security website, and key project documents uploaded;  Support for participation of delegates from Lao PDR and Viet Nam in three regional learning events (Bangkok ICAAP, IAC, ADB Regional Conference, October 2014), and one national learning event (Viet Nam National Scientific Conference on HIV and AIDS). Table 4: Summary of achievements against selected deliverables for Output 3

Output Selected Indicators Key Deliverables Achievements Output 3: Shared Documentation Production/publication of  Models for the two provincial pilot activities knowledge published of at least knowledge products with in Lao PDR, and three models in Viet Nam product on 75% of targeted content based on documented and shared at the bilateral regional Learning Sites and information generated by meeting on cross-border collaboration, Ha 10

Output Selected Indicators Key Deliverables Achievements cooperation on uploaded to the project activities, and Noi, 30 September-1 October 2014. HIV/AIDS websites dissemination online and prevention and in regional AIDS events management. Develop case studies,  GMS HIV website migrated to capacity development CDCII/Health Security website and report technical assistance on Ha Noi bilateral meeting uploaded, with (CDTA) briefers and key project documents and photographs brochures, popular media from cross-border meetings and TA field features and news visits;  Profile report seven border target At least 3 case studies provinces, including situation of HIV and and 1 research report AIDS and migration, capacity for, and published and uploaded experience in, cross-border HIV and AIDS to the websites prevention activities;  Four reports prepared, on three cross- border meetings, and one national-level bilateral meeting;  5 case studies prepared by national consultants, on migrants and vulnerable border populations, and bilateral MOU development. Participate in regional HIV  Support for participation of five Viet Nam and AIDS meetings and and eight Lao PDR delegates in the 11th conferences to share TA International Conference on AIDS in Asia and Project experiences and the Pacific (ICAAP), Bangkok, and learn from partners in November 2013. ICAAP. In addition, the other countries TA team assisted Dr Bounpheng Philavong, Director of CHAS, in preparation of his presentation at the ADB- supported ICAAP satellite session on “Reducing Vulnerability among Migrant and Mobile Populations and Communities in Cross-Border Areas in the GMS”; At least 3 regional  Support for booth and session on cross- learning events on border HIV and AIDS at Viet Nam National cross-border HIV Scientific Conference on HIV and AIDS, initiatives conducted Ha Noi, 2nd December 2013 The session, during the during the attended by over 50 people, included two-year project period presentations on lessons learned from previous experience in cross-border HIV programming between provinces in Viet Nam and those in neighboring countries, feedback from the ADB-supported satellite on cross-border HIV and AIDS at the recent ICAAP11 conference, and an overview of planned ADB support for cross-border HIV prevention between Viet Nam and Lao PDR under the GMS capacity building project;  Support for participation of Viet Nam Deputy Minister for Health, and registration 11

Output Selected Indicators Key Deliverables Achievements of Lao PDR delegates in 20th International AIDS Conference (IAC), Melbourne 20-25th July 2014;  TA experiences on cross-border MOUs, JAPs and pilot activity development shared in ADB Cooperation Fund for Fighting HIV/AIDS in Asia and the Pacific Regional Conference, 24th October, Bangkok, including presentation on MOUs by Dr. Bounpheng Philavong, Director, CHAS.

2.4 Additional assistance provided to the grant and loan projects and national responses in Lao PDR and Viet Nam In addition to activities directly related to achievement of the three key TA outputs, the TA consultants also supported the grant and loan projects in various ways, as well as providing assistance to the national programs in both countries in areas relevant to TA outcomes. In Lao PDR, where the process of preparation of a GFATM grant application is currently underway, TA consultants provided input to the development of TOR and planning for the Mid- Term Review, as well as the National Strategic Action Plan (NSAP) and concept note for the proposal. In Lao PDR the RCTA drafted the TORs for the CTA and Gender Specialist positions under the grant project. In Viet Nam, TA consultants provided input to VAAC in drafting the TORs for the loan project baseline survey. In both countries, TA consultants provided support to Government in the registration process and participation of country delegates invited to attend key international conferences and learning events, including the ICAAP conference, held in Bangkok in November 2013, and the International AIDS Conference, which took place in Melbourne in July 2014 (see section 2.3 above). 3. Monitoring and Evaluation activities Inception Missions were undertaken from 11th –15th June 2014, in Viet Nam, and 17th – 19th June, in Lao PDR. The first Review Mission in Lao PDR was fielded from 11–19th December 2013 to review the progress of PMU operations, review and agree the implementation mechanism of the “block grant”, and review and progress of TA implementation plan. A second Review Mission in Lao PDR was fielded on 17-22nd September 2014. The first Review Mission in Viet Nam was fielded in 31st March-4th April 2014. The objectives of the Mission were to (i) review workplan, implementation arrangements and covenants of the Project, the TA and the Grant; (ii) explain ADB's guidelines and procedures on consulting services, procurement and disbursement; (iii) identify any issues and adjustments to be made; and (iv) update the project administration memorandum (PAM). A second Review Mission in Viet Nam was fielded in 24-26th September 2014. The Final Consultation Mission (the Mission) 4 was carried out from 8-12th December 2014 to review the overall project outcomes. While the TA supported activities in both Lao PDR and Viet Nam, the Final Consultation Mission was conducted only in Lao PDR. General planning and implementation issues were discussed in relation to both countries, however field activities were considered on the Lao side only. No mission was conducted to Viet Nam. In conjunction with the Final Consultation Mission, a field visit to Attapeu was made from 9-11 December 2014 to look into the progress of the pilot project focusing on HIV prevention amongst Vietnamese migrant workers. The mission team reviewed with the finance team of the Attapeu PCCA Secretariat the arrangements for financial disbursements and liquidations for the cash advance for the pilot activities. A site visit was made to Saysettha District to observe HIV awareness raising activities with Vietnamese and Lao workers employed by the Hoang Anh company. More than 30 Lao and 62 Vietnamese workers attended the activity.

4Randy Dacanay, ADB consultant/Mission Leader, Liza Tabora, ADB Consultant, Marissa Espiritu, ADB Consultant, Scott Bamber, ADB Consultant, Chris Lyttleton, ADB consultant 12

4. Key Challenges and Lessons Learned TA 8204 implementation faced several important challenges, which impacted on the timing and successful implementation of activities according to the work plan. These include staffing issues, NGO recruitment for support of pilot activities, delayed implementation of pilot activities, limited scope of joint cross-border activities between the two countries, and the design of the TA project itself. Staffing issues, including resignations and delays in recruitment of replacement TA 8204 personnel, resulted in delays in implementation. The resignation of the original Viet Nam and Lao PDR National Coordinators presented significant challenges. Fortunately, a replacement Viet Nam National Coordinator was identified and recruited quickly, however, there was a 6-month gap between resignation of the Lao PDR National Coordinator in November 2013, and the commencement of his replacement in June 2014. The result was a slower than anticipated start to the TA activities in Viet Nam, while in Lao PDR, in addition to his regular duties, the RCTA also took responsibility for coordination with the PMU and CHAS during the period when there was no national coordinator. The recruitment of an NGO to design and support the implementation of provincial pilot activities did not proceed according to plan. TORs were finalised in July 2013 and expressions of interest sought, however by early 2014 the recruitment process had not progressed. There were several reasons for the delay in recruitment. One reason was the small number of NGOs that met the prerequisites in terms of country coverage, HIV and AIDS and cross-border experience. During the inception process the TA conducted a situational review to identify NGOs, both national and international, which met the selection criteria, results of which were summarised in a matrix completed in August 2014 (see document “GMS HIV and AIDS NGO and Organization Profiles”). In the process of compilation of this matrix, the TA team contacted and met with NGOs and briefed them on the TA project and pilot activities, and also gauged their interest in undertaking pilot project development and implementation. However, of the small number of NGOs that met the selection criteria, and indicated interest in the assignment, ultimately none submitted an application. From informal checks carried out by the TA team, it appears that, for locally-based NGOs, concern about staffing levels and capacity, and the burden of work involved in managing activities in widely separated provinces, was an important consideration. For international NGOs, staff changes in local offices, as well as the high administrative investment involved in such projects of relatively short duration, were key factors. As a result, the short-listed applicants consisted only of private firms. A second reason for the delay was that VAAC voiced disagreement with the composition and assessment rating of the short-listed applicants. This issue, which was not communicated to the RCTA at the time, apparently arose, in part at least, through the initial review and rating process, where, for one EOI, an annex containing supplementary information submitted with the completed official proposal form, was not shared with the RCTA. Based on the proposal form, the RCTA assessed the EOI as not meeting selection criteria and excluded the EOI from the short-list. Later, on request from ADB attaching supplementary documentation, RCTA reviewed the initial assessment, and found that the proposal met the minimal criteria for inclusion on the short list. The revised shortlist was resubmitted to ADB in late 2013, however, by February 2014, no further progress had been made on the selection process. For this reason, during the March 2014 ADB Review Mission to Viet Nam, a decision was made by ADB to abandon the NGO recruitment in favour of engagement of national consultants in each country to undertake the assignment. In view of the limited time available, this was considered as the most effective option. TORs were quickly developed for six national consultant positions, three in each country, comprising two technical consultants and one administration and finance position. The positions were advertised in April-May 2014 through the ADB CMS system. TA personnel consulted extensively with local partners to identify suitable candidates and encourage them to apply for the positions. Nevertheless, the national consultant recruitment process encountered challenges in identification of suitably qualified applicants, as well as their lack of familiarity with the web-based ADB CMS and application process. In Lao PDR, this process was further challenged by poor internet connectivity. In Viet Nam, while capacity of potential applicants or internet connectivity did not present difficulties, considerable pressure was exerted on the recruitment process by the EA/IA to promote candidates with close links to VAAC. As a result of these challenges, recruitment of national consultants in both countries was only finalised in July 2014. The delay in consultant recruitment meant that the provincial pilot proposals were not finalized until July 2014. This resulted in a significant reduction in the time available for implementation, including evaluation and documentation of

results. Proposals for pilot activities were completed by August 2014, however further delays in implementation resulted from the need for identification and agreement with implementing partners in both countries on a suitable mechanism for transfer of funds. In the course of ADB review missions to Lao PDR and Viet Nam in late September 2014 agreement was made to use the Advance Payment Facility (APF) mechanism. Owing to the revised time frame, national consultants had to make extensive revisions to the project work plans, budgets, and their own monitoring and technical support plans. Required documentation, including submission of country requests and provision of details of new bank accounts, for both countries was completed in October. In Lao PDR, the receipt of transferred funds was confirmed on 4 November, and the first tranche of funds were released to provinces on 26 November. The delay was due to the requirement by the PMU that the national administrative and financial consultant prepare detailed financial guidelines, and, initially, that provinces submit separate detailed requests for funds for each planned activity, to be signed by the PMU Director. This requirement differed from the mechanism for funds transfer to the provinces as originally envisaged, which anticipated transfer of a tranche of funds to the provincial account covering all planned activities. Later, the PMU relaxed this requirement, enabling a single request to be submitted by provinces covering all planned activities and funds to be transferred in a single tranche. It is important that this mechanism also be applied to the transfer of funds under the block grant mechanism under the grant project, otherwise significant delays in implementation of activities by the provinces could result. Several planned TA 8204 activities were not approved by ADB for implementation. These included two study visits and capacity building workshops, on the topics of Harm Reduction for PWID, and effective prevention of HIV among migrants and mobile populations. The topics for these activities were based on needs identified in the course of the provincial visits and profiles made in late 2013. In the northern provinces of Lao PDR, it was found that, due to staff rotation and continued low capacity at district and provincial levels, a further workshop and study visit on Harm Reduction was required. In Kontum province, it was found that increased awareness and knowledge of migration and population mobility was needed among provincial and district level personnel. In both sites, the opportunity for interaction between personnel in provinces in both countries afforded by participation in the study visits and workshops would make a valuable contribution to the development and implementation of pilot activities and cross- border cooperation. Following cancellation, selected components of these activities were incorporated into the provincial pilot activity proposals and JAPs finalised by the provinces in October 2014. Another important TA activity to be cancelled, at the direction of ADB, was the TA 8204 Project Wrap-up and Transition Meeting planned, originally, for early November. The wrap-up/transition meeting was included in the TA workplan from its initial preparation in 2013, with original plans for it to be held in Vientiane in early November 2014, in order to avoid possible conflict with the RSC meeting. Agreement on participation in the meeting was confirmed by both sides at the bilateral meeting in Ha Noi, on 1st October 2014. However, following delays in approval, the date was postponed to 19th-20th November, in Louang Prabang, to be held immediately before the RSC, then, after further delays in approval, Vientiane in early December, before confirmation of cancellation by ADB, for reasons of lack of commitment by the Viet Nam EA/IA. Cancellation was unfortunate, as a key activity in this meeting was planned to be the preparation of annual workplans for cross-border cooperation between each of the target provinces, and between CHAS and VAAC. These workplans complement the JAPs agreed in the bilateral meeting held in Ha Noi from 30th September-1st October 2014, and will provide a roadmap for continuation of cross-border activities under the grant and loan projects in 2015. With cancellation of the wrap-up/transition meeting, it is expected that this activity will now be undertaken by the implementing agencies in the two countries in early 2015. It is recommended that ADB follow- up closely with VAAC and PMU/CHAS to ensure that this meeting goes ahead as planned. Despite a willingness demonstrated by officials in both target provinces to develop productive working relations, this produced minimal joint activities. Pilot projects supported by the TA have some cross-border impacts (e.g. working with migrants) but are largely organised and managed by districts and provinces on the Lao PDR and Viet Nam sides without specific mutual coordination, apart from the planned cross-border coordination activities to be conducted under the provincial JAPs. Constraints include a lack of formal working approvals and activity budgets, resulting from differences in provincial regulations relating to cross-border travel, as well as lack of budget allocation for these activities under the grant and loan projects and other sources. These issues will be considered further in development of annual workplans.

In regard to the design of the TA project, several aspects presented significant challenges to the smooth implementation of activities. At the time of inception some key components of the project design document were not complete. Of primary importance among these was the DMF, for which only an early draft existed, and this was not included in the package of documents provided to the RCTA on commencement of assignment. On close examination of the DMF draft, it was apparent that the TA 8204 DMF was conceived separately from those of the grant and loan projects. As a piggy-backed project, it seems important that the TA DMF should be consistent with those of the main project. Also, on inception of the TA, it was assumed by consultants that there had been thorough discussion with the EA/IA in both countries, and there was understanding and agreement on all steps and procedures involved in implementation of the TA, including respective roles and responsibilities. Unfortunately this proved not to be the case, and TA personnel found that in both countries the EA/IA did not have a clear understanding of the purpose of the TA, how it was intended to contribute to the grant and loan projects, and the scope of work of TA personnel. Clarification of these issues required considerable effort on the behalf of TA personnel, leading to loss of valuable time in planning and implementation of activities. One aspect, in particular, which proved challenging was the mechanism for transfer of funds to TA personnel for costs of activities, for example the cross-border coordination meetings supported under Output 1. Some considerable time into implementation of the TA, personnel were informed by ADB that advance funds could not be transferred directly to TA personnel, or through the ADB resident missions in either country. As a result transfer of funds had to be made as separate tranches covering participants from each country, and in some cases direct payment by ADB Manila for costs such as hotel accommodation. Not only did this complicate liquidation arrangements, but it also increased the cost of activities, since equipment hire was made through the main venue, at higher cost, and it was not feasible to provide participants with a DSA and leave them to make their own arrangements for accommodation. Finally, in the original TA design, no provision was made for financial and administrative budget to cover office and other support costs. TA staff had to procure a printer/scanner, and also arrange a contract variation for the Lao PDR national coordinator, to cover this cost, as well as related supplies, paper and office stationery. It is recommended that the design of future projects of this nature include provision for a financial and administrative budget to enable technical personnel to focus on technical aspects of programming. 5. Sustainability and Transition Planning Overall the TA has made considerable progress towards goals in supporting and complementing the grant project in Lao PDR and the loan project in Viet Nam. At the same time, challenges faced during project implementation have provided valuable lessons that can be integrated into upcoming work in these provinces and elsewhere. The TA Project has established a framework for bilateral cooperation in cross-border areas. It has also developed innovative approaches for provincial-driven projects to address HIV prevention among migrants, mobile populations and other vulnerable groups. However, consideration needs to be given to the following actions:  Annual workplans complementing the MOUs and JAPs need to be completed and costed as part of the transition to grant and loan activities within the next budget year;  It is anticipated pilot projects will be carried on in subsequent years through support, in Lao PDR, from CHAS to the provincial PCCAs, and in Viet Nam, from VAAC to the PACs, through the block grant mechanisms. On the Lao PDR side, evaluation of impact and effectiveness of these pilot activities should be conducted so that any amendments can be included in upcoming workplans, so that, where assessments indicate that pilots have delivered significant achievements, they can be expanded to other districts in the target provinces. In Viet Nam, the pilot project proposals developed by national consultants under the TA need to be reviewed, workplans need to be developed for a three-year timeframe, and a plan developed for implementation and evaluation, so that, where appropriate, activities can be extended;  In order to assess how much capacity-building has been achieved by the TA activities that focus on pilot models for improving services to migrants and improving regional cooperation the capacity of provincial and district staff should be assessed as part of the grant and loan M/E activities in upcoming years.

6. Recommendations Based on the implementation of activities under the TA the following lessons learned can be identified and recommendations made: • Sustainable and high-impact cross-border activities are difficult to plan and coordinate. Future bilateral or regional loan projects may require an attached TA that can provide a facilitating mechanism to ensure coordination of regional and/or cross-border activities. Establishment and support for a regional/bilateral steering committee would be a central part of TA activities. Membership of this steering committee must have appropriate degree of decision-making ability to ensure recommended actions are undertaken and completed and thereby ensure genuine coordination of joint activities takes place. Consensus on milestones needs to be established so respective countries make coordinated progress on activities; • Piggy-backed TAs, such as TA 8204, should be designed as an integral and necessary component of the grant/loan projects to ensure that all parties agree on respective roles and responsibilities. The same DMF should apply to both loan and TA. Funding and financial arrangements need to be clearly defined; • Provision needs to be made for TA financial and administrative budget to enable technical personnel to focus on technical aspects of programming; • Engagement of NGOs for cross-border work needs an enabling environment, buy-in from government, availability of experienced NGOs and adequate time-frame; • The budget allocation for the pilot projects was included within the TA in order to ensure flexibility in activity design, NGO recruitment and civil society engagement. However it has also had the subsidiary effect of reducing the sense of ownership and responsibility of national governments to endorse and support the planning and implementation of these activities. This has ultimately diminished the effectiveness of this component and such modalities need to be rethought for future programs of this kind; • The project was able to build on previous HIV (SP10) and related projects in some of the border areas, in particular the Australian HAARP initiative that focused on HIV prevention among people who inject drugs in border districts in Houaphanh and Phongsaly provinces. But while SP10 provided some important groundwork, there has been minimal follow-up with the construction companies’ HIV work (also funded by ADB) as recommended by earlier reviews. This is in part due to the constant turnover of government staff in the local health offices such that there is reduced residual knowledge of previous project achievements.

7. Annexes 1. 2. DMF

Annex 1: TA 8204 Progress against TA 8204 Key Project Deliverables Progress Outputs Deliverables Due Date 30 September 2014 Output 1: Enhanced  Preliminary provincial  Completed May capacity for regional situational analysis/profiles 2014 planning and  Final situational  14 Nov 2014  In preparation (19 management of HIV analysis/profiles Dec) programs.  Preliminary review and  December 2013  Completed Dec assessment of regional 2013 covenants, joint initiatives, and policies on HIV/AIDS prevention on cross-border setting (RSC Siem Reap, Sept 2013 and Viet Nam national Scientific Conference on HIV/AIDS 2 Dec 2014)  Final review and  17 Oct 2014  Completed 30 assessment of regional September 2014 covenants, joint initiatives, and policies on HIV/AIDS prevention on cross-border setting (incorporated into MOU and JAP meeting Sept 2014)  Provincial MOUs for 2  June 2014  Completed June pairs of target provinces 2014  Final MOU  1 October 2014  Completed 30 September 2014  Provincial cross-border  1 October 2014  Consolidated draft Joint Action Plans for 3 for all target target province pairs provinces completed 1 October 2014  Draft 5-year strategic plan  1 October 2014  Completed 1 (identifying key areas for October 2014 cross-border cooperation and coordination)  Final 5-year strategic plan  17 Oct 2014  Pending ratification  Annual workplans to  14 Nov 2014  Pending implement the strategic plan

Progress Outputs Deliverables Due Date 30 September 2014 Output 2: Improved  Workplan for piloting of  Completed August access to and quality of interventions 2014 HIV services for migrants  Initial design of pilot  Completed August and mobile populations interventions 2014 at border provinces.  Final design of pilot  Completed August interventions per selected 2014 project area  Initial assessment of pilot  17 October 2014  Pending (Lao PDR implementation only)  Final assessment of pilot  5 Dec 2014  Pending (Lao PDR implementation only)  Documented pilot  15 Dec 2014  Pending (Lao PDR interventions for outreach only) and service provision for migrants and mobile populations and key populations at high risk settings

Output 3: Shared  List of knowledge products  30 June 2014  Completed knowledge product on and dissemination September 2014 regional cooperation on activities HIV/AIDS prevention and  Knowledge management management. workplan (schedule,  4 July 2014  Pending dissemination, audience, peer review, etc.)  First draft of KPs  3 Oct 2014  Pending  Final draft of KPs  17 Oct 2014  Pending  Production/Publication of  23 Oct-12 Dec  Pending KPs 2014  Regional workshop design  24 Oct 2014  Completed for knowledge exchange  Regional workshop report  Completed (by ADB)

Output 4: Project  July-December 2014  4 July 2014  Completed Management revised workplan  Mid-term progress report  4 July 2014  Completed  Final report  Workshop reports  20 Dec 2014  Completed  Block grant design  11 July 2014  Pending (revised) – fund flow, etc  8 August 2014

Annex 1: Design and Monitoring Framework (DMF) Performance Targets and Data Sources and Design Summary Assumptions and Risks Indicators with Baselines Reporting Mechanisms Impact Assumptions Enhanced regional HIV 70% increase in financial National and provincial • Governments considers response system commitment of DMCs in annual HIV reports cross-border HIV prevention cross-border HIV and control for mobile and prevention and control Project-supported surveys migrant population as a at end-line to assess impact critical intervention 80% increase in number of migrant and mobile • Regional cross-border PPMS reports populations accessing coordination HIV/AIDS information and mechanism/body functional services and supported by key officials

• Cross-border HIV services sufficient, available and accessible to migrant and mobile population

Risks • Government does not support cross-border interventions on HIV prevention

• HIV services Insufficient, unavailable or inaccessible to migrant and mobile population Outcome Assumption Improved HIV/AIDS Policy supporting National and provincial • Governments are willing prevention and management establishment of cross- annual HIV reports and able to institutionalize at cross-border provinces in border coordination and capacity, systems and Viet Nam and Lao PDR collaboration mechanism in Minutes of meetings of mechanisms for regional place in all the relevant regional coordination coordination national and provincial mechanism, annual offices by 2017. program of action, assessment reports Coordination and PPMS reports collaboration mechanisms for cross-border HIV intervention established and functional, with strategic and annual workplans and budget in all Lao and Viet Nam provinces covered by the project by 2017

Government-designated focal persons with clear TOR for cross-border coordination and collaboration by 2013

Performance Targets and Data Sources and Design Summary Assumptions and Risks Indicators with Baselines Reporting Mechanisms Outputs Assumptions Framework for regional National/Provincial health 1. Enhanced capacity for • Enabling policy cross-border HIV and AIDS department’s routine regional planning and environment in the DMCs to responses between Lao PDR reports management of HIV allow regional HIV response and Viet Nam established in programs system all TA provinces. • Governments are willing 5-year strategic plan and able to institutionalize developed and implemented capacity, systems and (2013-2017) mechanisms for regional Annual workplans coordination developed and implemented PPMS reports Risks by provincial HIV committees during the two- • Some government policies year project period might restrict opportunities for effective regional HIV response system

Assumptions 2. Improved access to and Joint collaborative activities National/Provincial health • National and provincial quality of HIV services for in the border areas between department’s routine governments agree to mobile and migrant the two countries identified reports establish learning sites in the populations at border and implemented during the border areas and to provide provinces. two-year project period outreach services to migrant

and mobile populations Joint HIV and AIDS

outreach and service Risks provision conducted for at PPMS reports • Inadequate trained staff to least 50% of targeted provide information and migrant and mobile services to migrant and populations in two years. mobile population Appropriate modalities for cross-border HIV prevention and treatment piloted and documented in at least 2 of the Lao and 2 of the Viet Nam target provinces.

3. Shared knowledge product Documentation published of National/Provincial health on regional cooperation on at least 75% of targeted department’s routine HIV/AIDS prevention and Learning Sites and uploaded reports management. to the websites.

At least 3 case studies and 1

research report published and uploaded to the websites. PPMS reports At least 3 regional learning events on cross-border HIV initiatives conducted during the during the two-year project period

Activities with milestones Inputs

Output 1: Enhanced capacity for regional planning and management of HIV • Cooperation Fund for programs Fighting HIV and AIDS $1,000,000 1.1 Conduct a regional workshop to review scope and effectiveness of current • The governments will coordination mechanisms for cross-border HIV and AIDS responses between Lao provide counterpart PDR and Viet Nam, including MOUs and other agreements, and develop a joint plan support in the form of for revision of existing agreements and/or development of new agreements counterpart staff, office 1.2 Develop and finalize TOR for cross-border coordination and cooperation mechanism accommodation and local including designation of focal point persons and conduct first official meeting to transport whose value is define a functional cross-border mechanism estimated to account for 1.3 Conduct annual review and planning workshop for regional cross-border cooperation 15% of the total TA cost. mechanism 1.4 Conduct a review workshop on regional planning capacity and coordination for cross- border HIV and AIDS responses to develop a joint 5-year strategy for planning and implementation of cross border collaboration, and identify needs and a plan for capacity building 1.5 Conduct a minimum of 3 capacity building training workshops and other capacity building activities on skills for cross-border HIV and AIDS planning and coordination for relevant agencies and key stakeholders implementing regional cooperation and coordination on HIV prevention

Output 2: Improved access to and quality of HIV services for mobile and migrant populations at border provinces

2.1 Conduct assessment of target border provinces for capacity to analyze cross-border HIV risk and vulnerability, and develop and implement responses. 2.2 Develop NGO TORs, select and engage NGO for support for situational assessments of target sites, development of proposals for pilot cross-border activities and technical support during start-up. 2.3 Complete situational assessments for target site, with a risk assessment describing local vulnerabilities to HIV and AIDS, local capacity in service delivery for reducing HIV prevalence and treating AIDS, and prioritized recommendations for responses. 2.4 Develop and provide TA for implementation of pilot activities in at least 3 locations to address local vulnerabilities to HIV transmission, with a focus on trans-border migrant workers, ethnic minority communities and populations in remote villages. 2.5 Document models for cross-border HIV service delivery 2.6 Conduct annual regional progress review workshop of pilot activities, including exchange of insights, experiences and lessons learned on cross-border cooperation

Output 3: Shared knowledge product on regional cooperation on HIV/AIDS prevention and management

3.1 Publication of knowledge products and dissemination in regional AIDS events 3.2 Conduct regional learning events on HIV, migration, cross-border service provision etc. 3.3 Develop case studies, capacity development technical assistance (CDTA) briefers and brochures, popular media features and news

RETA-8204 Completion Report: December 2014 22 Case Study

Implementing Technical Assistance Pilot Program on HIV Prevention Among Vulnerable Populations in the Border Areas of Houaphanh and Phongsaly Provinces, Lao PDR: lesson learns from project implementing staff

Manivne Thikeo, MD, MPH, Ph.D., National Consultant for TA-8204; Scott Bamber, Ph.D., Regional Program Advisor for TA-8204

I. Background introduction

The estimated prevalence of HIV in Phongsaly and Houaphanh provinces is relatively low, being less than 1%. No data is available on prevalence among key affected populations apart from the 17% prevalence rate among a sample of people with injecting drug (PWID) identified in a 2010 rapid assessment.1 But the number of confirmed cases of Sexual Transmitted Infection (STI) is high in districts adjacent to Vietnam (e.g., 20% in Mai District in 2013), with the majority among females. The few Volunteer Counselling and Testing (VTC) sites are largely irregular since full- time staff are not always available. Both provinces have a large migrant population mainly from neighbouring countries, China and Viet Nam, and include sex workers, traders and labourers. The potential for a concentrated HIV epidemic among people who inject drugs has been established in two northeast provinces. Injecting drug use appears to be widespread at the four districts bordering to Viet Nam where the HIV/AIDS Asia Regional Program in Lao PDR (HAARP Laos) Needle Syringe Assistance Program (NSAP) reaches 60 PWID in Maung Mai district in Phongsaly province and 80 PWID in Xiengkhor, Sopbao and Viengxay districts in Houaphanh province.

HAARP was an Australian Government (DFAT) funded regional program focusing primarily on HIV prevention among people who inject drugs in Southeast Asia and China and implemented from 2009 to 2014. A rapid assessment and response study (RAR) conducted by HAARP program identified 9 and 37 heroin injectors in Phongsaly and Houaphanh Provinces respectively, among the 549 drug users sampled. A rapid assessment and response study conducted in 20102 also established a 17% HIV infection rate in 46 PWID, among a sample of 549 drug users in Houaphanh and Phongsaly provinces. The HAARP Laos survey identified six heroin injectors in Houaphanh province and two in Phongsaly province who were HIV positive. Both provinces have a high prevalence of drug users from decades of opium cultivation and their location on narcotics trafficking routes.

1 Rapid Assessment and Response to Drug Use and Injecting Drug Use in Houaphanh and Phongsaly Provinces in Lao PDR. HAARP, LCDC, CHAS, UNODC. 2010. 2 RAR 2010 1

In 2011, HAARP Lao PDR began a NSAP in Houaphanh and Phongsaly provinces to address the HIV burden from sharing of unsterile injecting equipment. The Lao National Commission for Drug Control and Supervision (LCDC) with the support of the Centre for HIV/AIDS and STI (CHAS)3 were the primary implementing partners of HAARP. The UNODC and the DFAT post in Vientiane jointly provide technical supervision and capacity building. Activities were monitored by provincial and district counterparts of LCDC and CHAS under this bilateral arrangement.

The Lao PDR - NSAP 2011-15 prioritizes HIV prevention among PWID, stating that “Drug users need to be urgently targeted, especially those using opiates, as international evidence indicates they are prone to injecting”. Moreover, halting or reversing the spread of HIV/AIDS among them and ensuring their access to treatment by 2015 to achieve the Millennium Development Goals (MDG) will stipulate that:  60% of the estimated 1,150 people4 who inject drugs are reached with safe injecting equipment and condoms  HIV prevalence amongst PWID (and other populations at-risk) is under 5%  Reported safe use of injecting equipment by PWID is at 55%  Reported consistent condom use with any partner by PWID is at 55%

After the announcement of Australian Government to end HAARP in April 2014 several key planned activities were not implemented and on-going support for the NSAP was not possible. A point-of-care referral system (POC), was originally planned to be implemented by HAARP from 2014 to link the NSAP with HIV counseling and testing, and AIDS treatment services at secondary and tertiary health facilities in both provinces. It will now be implemented through CHAS and in conjunction with the Asian Development Bank Greater Mekong Subregion HIV Prevention Capacity Building Program and the associated Technical Assistance Project. In view of the consistency between HAARP target populations, objectives and activities, and the proposed outputs of the pilot activities under the Asian Development Bank project, in January and February 2014, HAARP and the Australian Government DFAT post in Lao PDR met with Asian Development Bank Technical Assistance staff, as well as the Director of CHAS, to discuss the possibility of continuing support for some key HAARP activities under the ADB TA-8204 and grant projects. Subsequently, HAARP developed a draft proposal, including ongoing activities and outputs, which are consistent with the draft guidelines for block grant funding under the ADB grant project.

3 CHAS is delegated to work with HAARP by the Ministry of Health Department of Communicable Diseases Control and Health Care 4 This is an extrapolated estimate. There is no current reliable estimate of IDU populations in Lao PDR. NSAP 2011‐ 2015. CHAS, MOH Lao PDR. 2

The Technical Assistance Pilot Program on HIV prevention among vulnerable populations in the border areas of Houaphanh and Phongsaly provinces was built on ongoing interventions by HAARP that currently benefit vulnerable groups and their families living in 24 villages including five health centers in four target districts in Houaphanh and Phongsaly provinces. This includes 152 PWID clients that are supported by the NSAP. The proposal developed under ADB TA- 8204 support aims to address the vulnerability to HIV infection of individuals and communities at two partner province cross-border areas between Lao PDR and Viet Nam, in particular people who inject drugs, sex workers, men having sex with men, and mobile/migrant populations who live or travel across the provinces designated:

 Houaphanh Province (Lao PDR) – Son La and Thanh Hoa Province (Viet Nam)  Phongsaly Province (Lao PDR) – Dien Bien Province (Viet Nam)

In addition, the program aims to strengthen the capacities of provincial, district and village authorities, and local stakeholders (i.e., Women’s Union, Youth Union) to create awareness about HIV and AIDS among their constituencies, and to lead services provided through the health system (e.g., VCT, ART, STI/TB counselling and treatment) or through the community (e.g., outreach, peer education).

II. Lessons learnt from TA project implementation in Houaphanh and Phongsaly Focus groups and in-depth interviews were conducted with TA project implementers and formal HAARP project collaborators in Hoauphanh and Phongsay provinces. The provincial TA pilot project implementing staff in both provinces were assigned by the Provincial Health Offices (PHO) to take responsibility and carry out the TA-8204 under support and guidance from TA consultant team. The Houaphanh team has six staff while the Phongsaly team has only four staff, who represent PCCAs, HIV and STIs outreach educators, account and finance officers implementing the TA pilot project. The implementing team works collaboratively with district health departments, health centers, head of villages and peer educators who are formal or current drug users in the target areas to implement the project under technical support and guidance from the National Consultants of TA-8204. Although the TA project planned to commence implementation in mid-2014, however, due to some technical challenges, the project was able to initiate activities in the target areas only at the beginning of November, and ended support at the end of December. Activities will receive continued support through CHAS with block grant funding under the ADB grant project. During focus groups and in-depth interview discussions, the implementers from the Houaphanh team reported that they are very happy with the TA project because they have been part of the project since its initial development, data collection, proposal development, budget and preparation of the activities plan. They also shared that the most impressive aspect of the TA

project is the collaboration and communication between TA team and provincial counterparts to prioritize the most importance activities that meet priority needs of the province and beneficiaries in the target areas. The most important is the clear budget and ownership of its management given to the provincial teams by the TA project. Although Phongsaly team has relatively less contribution to the initial TA project development, the team reports similar experience and perception toward TA pilot project and working with TA consultants during the project preparation and implementation as well as field monitoring. Along with the positive feeling toward TA pilot project, there are several challenges that the teams from Hoauphanh and Phongsaly brought up. The teams shared that they feel very challenged to implement the TA pilot project within the very short timeframe and thus they have not had much time to prepare with their counterparts from districts, villages, and beneficiaries in the target areas. In addition, they also report that although they have more skills and experience with implementing HIV and others communicable disease projects, they have very limited knowledge and experience with PWID particularly outreach education and motivate users to participate in the NSAP as well as VCT. Moreover, the challenging geography and poor access roads to the areas make it harder for the implementing staff to reach beneficiaries in remote target areas particularly at border between Lao and Vietnam. Beyond infrastructure and geographical challenges the implementing team from Houaphanh found very difficult to work with users who are not only smoke poly-substances but also inject high dosages of heroin and opium. While the Houaphanh team shared their challenges in delivery HAARP and TA pilot projects between implementing partners in each of the target areas and poor communication network systems make it harder for the team to communicate effectively and delivery the activities on target timeline. In addition, the Phongsaly team has also been confronting with recruiting peer educators who used to participate with HAARP project to deliver the activities of the TA pilot project. Another challenge that confronted the Phongsaly team is that the HAARP project was directly implemented in Muang Mai under collaboration with District Health Department and District Drug Control Office. The PHO in Phongsaly had not been involved with the HAARP project and thus they had very little knowledge of the activities HAARP had carried out in the target areas in Muang Mai. Therefore, the Phongsaly team needs to spend more time focusing on building an effective team work to implement the pilot project before recruiting more peer educators. After the HAARP project ended in April 2014, the number of peer educators in Muang Mai was reduced, either through death from drug over-dosage, infection due to sharing and using unsterile injecting equipment, or migration to other provinces. During group discussions with the Phongsaly team in Muang Mai, the team requested more financial support to recruit more peer educators to serve each target area, due to the recent increase in the number of users since the HAARP project ended. Beyond asking more support to recruit peer educators, the district team

in Muang Mai also expressed the need for more administrative support as well as support for creating a separate facility for HIV and PWID activities and vehicles to carry out the grant project. The district has limited administrative staff and lack of a vehicle to conduct activities in the target areas. The district office shared that, with the recent increase in the number of drug dealers and users in the areas, there will be more requests for outreach and delivery of NSAP to prevent future HIV/STIs infections in addition to preventing deaths from drug over-dosage. Therefore the team has to work harder to deliver services to the beneficiaries and to motivate users via peer educators to practice safe sex and use of the needle syringe exchange program at the health center instead of sharing unsterile injecting equipment. When asked what TA project activities the teams would suggest to continue to carry on under the grant project, both Houaphanh and Phongsaly expressed that all activities developed under TA pilot project are very important to be continued. However, both requested more capacity building and training on PWID and project monitoring as well as report writing.

III. Recommendations Several achievements and lessons have been learnt during the short period of TA pilot program implementation in Houaphanh and Phongsaly provinces. Both teams from Houaphanh and Phongsaly have been working hard with the TA consultant team to carry out the activities in the target areas. The Phongsaly district team was able to recruit 8 peer educators who are representative of users in the different target areas and they used to participate in HAARP program in Muang Mai. This reflects the very significant commitment and hard work of the provincial and district staff toward implementing TA pilot project. However, due to geographical challenges in both provinces, particularly Phongsaly, more support and guidance to motivate staff to carry out activities on target timeline is crucial for program success. In addition, close communication and development of strong team work between provincial and district level are recommended to carry out the activities in the target areas. Both provinces have limited capacity in terms of writing reports related to activity implementation, budget expenses, and daily administrative work. In future the project needs to provide close supervision and monitoring on budget and activity reports as well as building strong team work and better communication among implementers and partners, which will lead to program success. Special attention needs to be paid to the Phongsaly team because they have limited capacity and staff to carry out the project. In addition, geographical challenges and poor network communication systems in the areas limit the Phongsaly team in effective implementation of the project. Close supervision and support is highly recommended and needed specifically for building the strong team work between provincial and district office of Phongsaly team. More support and hands-on assistance to the Phongsaly team is crucial. If possible, at the initial phase of the project implementation, it would be beneficial to have staff from the Vientiane Office spend more time in Muang Mai to assist Phongsaly team for project planning and implementation. In addition, it would also be

beneficial if a plan be developed for regular monitoring and technical support and/or mentoring. Overall the teams in both provinces collaborate well and are highly motivated, and this will increase if more support can be made to them. There is no doubt that both provincial teams will do well and experience success in implementing future grant project in the target areas if they receive more support and guidance from CHAS and PMU offices.

Case Study 2

HIV Prevention Among Vulnerable Populations in the Border Areas of Houaphanh and Phongsaly Provinces, Lao PDR: Peer Educators’ experiences delivering Needle and Syringe Exchange Program

Manivone Thikeo, MD, MPH, Ph.D., National Consultant for TA-8204; Scott Bamber, Ph.D., Regional Program Advisor for TA-8204

I. Background introduction

The prevalence of HIV in Lao PDR particularly in Houaphanh and Phongsaly provinces is relatively low, being less than 1%. No data is available on prevalence among key affected populations apart from the 17% prevalence rate among a sample of people with injecting drug (PWID) identified in a 2010 rapid assessment.1 The potential for a concentrated HIV epidemic among people who inject drugs appears to be widespread at the four districts bordering to Viet Nam where the HIV/AIDS Asia Regional Program in Lao PDR (HAARP Laos) Needle Syringe Assistance Program (NSAP) reaches 60 People With Injecting Drug (PWID) in Muang Mai district in Phongsaly province and 80 PWID in Xiengkhor, Sopbao and Viengxay districts in Houaphanh province.

II. The Needle Syringe Exchange Program for people with injecting drug use

HAARP was an Australian Government (DFAT) funded regional program focusing primarily on HIV prevention among people who inject drugs in Southeast Asia and China and implemented from 2009 to 2014. In 2011, HAARP Lao PDR began a NSAP in Houaphanh and Phongsaly provinces to address the HIV burden from sharing of unsterile injecting equipment. A point-of- care referral system (POC) was planned to commence in 2014 to link the NSP with HIV counseling and testing, and AIDS treatment services at secondary and tertiary health facilities. Lao PDR-NSAP 2011-14 prioritized HIV prevention and reversing the spread of HIV and AIDS among PWID in addition to ensuring their access to treatment by 2015 to achieve the Millennium Development Goal (MDG), which stipulates that:  60% of the estimated 1,150 people2 who inject drugs are reached with safe injecting equipment and condoms  HIV prevalence amongst PWID (and other populations at-risk) is under 5%  Reported safe use of injecting equipment by PWID is at 55%  Reported consistent condom use with any partner by PWID is at 55%

1 Rapid Assessment and Response to Drug Use and Injecting Drug Use in Houaphanh and Phongsaly Provinces in Lao PDR. HAARP, LCDC, CHAS, UNODC. 2010. 2 This is an extrapolated estimate. There is no current reliable estimate of IDU populations in Lao PDR. NSAP 2011‐ 2015. CHAS, MOH Lao PDR.

In April 2014, the Australian Government announced the end of the HAARP project and several key planned activities were not implemented; on-going support for the NSAP was not possible without continue support from other funders. To continue support for the project, HAARP, Asian Development Bank (ADB), and Center for HIV, AIDS and Sexual Transmitted Diseases (CHAS) met and discussed ongoing support NSAP in Huoaphanh and Phongsaly provinces under grant project from the ADB. HAARP developed a draft proposal, including ongoing activities and outputs, which are consistent with the draft guidelines for block grant funding under the ADB grant project. The NSAP will now be implemented through CHAS and in conjunction with the Asian Development Bank Greater Mekong Subregion HIV Prevention Capacity Building Program and the associated Technical Assistance Project. 1. The Needle and Syringe Exchange Program

NSAP is the only community-based health outreach in the country that is led by former and current drug users at village level and reaches both Lao and Vietnamese (~20-30%) clients. The outreach strategy of the NSAP includes:

 24 peer educators (PE) who distribute sterile needles and syringes, condoms and IEC materials to 152 PWID clients who receive an average of three needles weekly  brief interventions for behaviour change by PE using various IEC materials on safer sex and safe injection (i.e., safer drug use, such as vein care, overdose management) in Lao, Hmong and Vietnamese languages3  awareness events at villages and the provincial/district capital (e.g., World AIDS Day) organised by narcotics and AIDS control staff health centre staff, PEs and their village heads  referral to VCT, STI or ART at various sites within the province or nearby (but locals often use health facilities in Viet Nam, e.g., Dien Bien Provincial Hospital)

2. Point-of-care (POC) referral system

This decentralised approach is planned for Houaphanh Province and will refer clients through a cycle of services designated as the ‘4 points of care’. A minimum package of HIV and AIDS services will offer:

 HIV prevention – needle and syringe program (NSP), voluntary counselling and testing (VCT), screening for sexually-transmitted infections (STI) and tuberculosis (TB)  AIDS treatment – screening and treament for AIDS opportunistic infections, anti- retroviral therapy (ART)  Care for people with AIDS – peer counselling, self-help groups, home-based care

3 IEC materials are brochures, A4/poster‐size flipcharts and posters

The Technical Assistance Pilot Program (TA-8204) on HIV prevention among vulnerable populations in the border areas of Houaphanh and Phongsaly provinces was built on ongoing interventions by HAARP that currently benefit vulnerable groups and their families living in 24 villages including five health centers and 152 PWID clients that are supported by the NSAP in four target districts in Houaphanh and Phongsaly provinces.

The NSAP developed under the ADB TA-8204 aims to address the vulnerability to HIV infection and harm reduction of individuals and communities at two partner province cross- border areas between Lao PDR and Viet Nam, in particular people who inject drugs, sex workers, men having sex with men, and mobile/migrant populations who live or travel across the provinces designated:

 Houaphanh Province (Lao PDR) – Son La and Thanh Hoa Province (Viet Nam)  Phongsaly Province (Lao PDR) – Dien Bien Province (Viet Nam).

III. Lessons learnt from peer educators delivering services to the target groups in Houaphanh and Phongsaly provinces. Focus groups and in-depth interviews were conducted with peer educators in Viengxay, Sopbao, Xiang Khor districts in Houaphanh province and Muang Mai district in Phongsaly province. The focus groups and in-depth interviews were carried out during NSAP activities in each district. There were 15 peer educators from three districts in Houaphanh province and one district in Phongsaly province participated in focus groups and in-depth interviews. There were four participants, two head of villages, one formal and one current drug user, participate with focus group at the Khoun Health Center in Viangxay district. The peer educators who are current or formal users from Sopbao and Xiang Khor districts were not available to participate in the focus groups due to Hmong New Year celebration. Therefore only head of the target villages in Sopbao and Xiang Khor district who lead and supervise peer educators and NSAP participated in the focus groups at the district departments of health. All peer educators were selected by the head of villages under collaboration with district health department, which is responsible for implementing TA-8204 and block grant project. All peer educators were trained to deliver NSAP and HIV awareness education from HAARP project. The peer educators in Viengxay group shared current drug users in their target areas are Lao and Vietnamese. The Lao drug users only smoke poly substances while Vietnamese migrants who cross border to work every week engage in intravenous drug injection. There are 17 drug users participating in the peer education program in Viengxay. Recently 2 persons died from drug over dose and 2 have been incarcerated, and there are 13 current drug users, including 2 females, who smoke poly substances. The peer educators and village heads reported that there have been increasing numbers of migrant Vietnamese who inject drugs in the NSAP target area.

The peer educators and drug users in Sopbao and Xiang Khor districts are ethnic Hmong. According to the village heads and health center staff from Sopbao, there has been an increase in numbers of PWID in their target areas, although the actual number of current users is unknown. Three village heads and one health center representative from the four target villages in Xiengkhor district participated in the focus group discussion. The Phiangsa village head reported that there are 17 drug users with 9 females and 1 injecting drug user in the village. The Nakhang village head reported more than 20 drug users, with 8 females who currently either smoke poly substances or inject drugs. The Keolom village head informed the group that there are 7 PWID, with 1 female, in his village. Eight participants, comprising 2 village heads and 6 drug users, participated in a focus group held in Muang Mai district in Phongsaly province. The peer educators comprise both Laoloum (lowland, or ethnic, Lao) and Hmong, who conduct outreach in the target villages in Muang Mai district. They reported that since HAARP ended in April there have been an increased number of drug users in the town and surrounding villages. There have also increased in numbers of drug activities in the town, particularly at the entertainment facilities. The peer educators and village heads reported that there are currently 55 PWID participating in NSAP in Muang Mai. However, the actual numbers of PWID are particularly high in villages in the town of Muang Mai. The peer educators and village heads informed the group that since the HAARP ended project there has been an increase in using and sharing of unsterile injecting equipment among PWID, leading to recent higher numbers PWID dying from infections in Muang Mai. The peer educators across four groups in Houaphanh and Phongsaly provinces stated that they proud of themselves for being recognized by the project and authorities in the area to do outreach work. They also said that they feel good being able to help other users in the target areas. They are very happy that the TA-8204 was able to support NSAP and peer educators to continue outreach education and deliver injecting equipment to beneficiaries. All participants shared challenges they have faced in delivering NSAP. The most challenging aspect for them is the difficulty of travelling from their villages to target areas because of poor infrastructure and mountainous without access roads. One participant said that it took him half a day to travel from his village to the health center to obtain medical supplies. Because there is no access road from his village, he has to travel by motorbike from his village to another village where he can rent a boat to carry him to the village where health center is located to obtain injection equipment and IEC materials. All PEs said that the incentive they have received from the project is too little and can’t cover the cost of travel to pick up supplies at the health centers. Some PEs stated that their families do not support them to do the outreach work due to low incentive and their families do not have enough money to pay for their fuel and food for travel to the health center to pick up equipment or attend meetings. They expressed the view that the low incentive will draw people away from doing outreach work. They requested that in future the project increase the per diem rate, from the rate of 360,000 kip/month that they used to receive from HAARP project.

The peer educator from Viangxay stated that his challenges are not only poor access road but are also the risk of relapse triggered by seeing and smelling the drugs used by his peers in the target areas when he delivers services to them. He has been off drugs for one year, through home based treatment using methadone obtained from Vietnam by his family. Several peer educators who are current users stated that they want to stop using heroin and other drugs but they can’t afford treatment from the methadone clinic in Vietnam. Some participants said that they received treatment with facilities in Laos but relapsed when they returned to their homes in the target area. The majority of peer educators and current users expressed their need for help to access treatment. Participants from Muang Mai district reported that they have witnessed the recent death of their peers due to sharing and using unsterile injecting equipment. The group report found unsterile injecting equipment piled up in one crack house in Muang Mai where many users were lying on the floor waiting to share needles with their peers. One participant shared that he has reached out to his peers to educate them not to share or use unsterile equipment by giving them new syringes and needles that he has left over from the HAARP project. All participants from across four groups stated that majority of drug users do not want to participate in the NSAP because of a misbelief that the equipment from the project contain toxins and will kill them. All of them admitted that they have limited capacity and knowledge related to drug abuse and transmission of HIV or other diseases. They want to have more training on drug abuse and how to stop the habit. In addition, they want to have more awareness campaigns and outreach from authorities to make people aware of the dangers of using substance, and the treatment available; if possible they would like to have campaign materials in Hmong and Vietnamese languages, which would be a great help. During the group discussion in Muang Mai, some participants stressed their feeling of hopelessness in trying to stop using substances. However, if treatment is available and accessible for free, then they want to try. Participants from Viengxay and Muang Mai shared their opinion that NSAP is good for preventing the spread of HIV infection but it would be better if there is treatment available to help them stop using substances and become productive citizens. Participants from across the four groups stated that they want to have psychosocial support groups available to them after treatment and recovery to prevent relapse and to help learn vocations to earn an income. All participants feel grateful to have NSAP continue under the block grant scheme and they expressed the wish to have more support from project staff on both capacity building training and incentive for them to continue carry out the activities in the target areas particularly in the remote mountainous border area between Lao PDR and Vietnam. IV. Recommendations Several lessons have learnt from participants during focus group discussion in Houaphanh and Phongsaly provinces. Although all participants have some background working and training from HAARP project, it would be beneficial if more training relate to knowledge and awareness of drug abuse can be provided to them. All participants appeared to be motivated to do the work

because they feel recognized by the authorities even though the incentive is low. To continue to engage them in the project, to increase their motivation and to make them feel good about themselves and their duties, in future the project should consider not only an increase in the rate of the incentive, but also giving them a certificate of recognition, which would be highly beneficial. Since the majority of users expressed the desire to stop using substances it would also beneficial if a treatment assistance plan can be developed as a future project beyond the NSAP. Due to the increased number of deaths from reusing and sharing unsterile injecting equipment, particularly in Muang Mai district, increased outreach activities, with a focus on VCT, would be beneficial and potentially stop deaths and the spread of HIV infection among PWID. Relapse prevention is a challenge to establish in the context of limited resources. However, if a psychosocial support program can be developed to support those who have already ceased drug use; it would benefit and prevent them from relapse when conducting outreach peer education work. Since the majority of the peer educators who have participated in the TA-8204 are current users, close monitoring and support from project and local staff are highly recommended to make sure they get enough support when needed. It would also be beneficial if regular meetings and monitoring be undertaken, as well as development of a mentoring plan to support onsite staff and peer educators. It would also be helpful if in future the project develops a meeting plan to exchange knowledge and lessons learned from the experience of Provincial Committees for Drug Control (PCDC) and District Committees for Drug Control (DCDC) in implementing NSAP in the target areas. Meetings with PCDC and DCDC would be crucial for the future project to avoid making the same mistakes HAARP might have made, and to increase the effectiveness of future project implementation in the target areas.

Case Study Development of MOUs on Cross-border Coordination for HIV and AIDS Prevention

1. Introduction In December 2011 at the Greater Mekong Subregion (GMS) Summit in Myanmar, an agreement was signed between the six GMS countries of Cambodia, PRC China, Lao PDR, Myanmar, Thailand and Viet Nam addressing HIV Vulnerability related to population movement. This agreement, the Memorandum of Understanding (MOU) for Joint Action to Reduce HIV Vulnerability Related to Population Movement, has two main goals: i) to reduce HIV vulnerability; and ii) to promote access to prevention, treatment, care and support among migrants and mobile population and affected communities in countries in the GMS. Four areas of collaboration are outlined: 1. Promote improving policy environment and enabling mechanisms; 2. Promote community-based strategies that reduce HIV vulnerability; 3. Promote access to HIV and AIDS prevention, treatment, care and support; 4. Monitoring and evaluation. At the time of signing of the MOU, it was understood among the GMS countries that the GMS MOU would provide a regional framework that would be complemented by additional MOUs agreed by individual countries on a bilateral, or in some cases, a trilateral, basis, as well as agreements between provinces within these countries that share borders. In support of this process, under the ADB-funded Regional Capacity Development Technical Assistance for Greater Mekong Sub-region Capacity Building for HIV/AIDS Prevention Project (TA 8204), in 2014 MOUs were signed, at the provincial level, between five provinces in Lao PDR and Viet Nam, and at the national level, between the Viet Nam Administration of HIV/AIDS Control (VAAC) and the Lao PDR Centre for HIV and AIDS and STI (CHAS). An existing MOU between two provinces was also reviewed and validated. This document is intended to provide a brief description of the process by which these agreements were developed, and their content, in order that the experiences and lessons learned can serve - bearing in mind the considerable differences in the situations in each country - as a resource for other countries in the region considering the preparation of similar agreements. 2. Partnerships, Roles and Responsibilities Consultants engaged under the TA 8204 project facilitated by the process for development of all MOUs. At the national level this was done in close coordination with VAAC in Viet Nam, and CHAS and the Project Management Unit (PMU) of the Ministry of Health, in Lao PDR. At the provincial level, the process was carried out in close coordination with the Provincial Health Departments, as well as Provincial Committees for Control of AIDS (PCCA), in Lao PDR, and Provincial AIDS Committees (PACs), in Viet Nam, together with VAAC, and PMU/CHAS. HIV and AIDS agencies in both countries were responsible for liaison and with other key agencies, such as ministries of foreign affairs, national and border security etc, and obtaining necessary clearance as required. 3. Content The general framework for all MOUs was based on the content of the GMS MOU, with changes made to accommodate specific country contexts (see summary of the GMS MOU content in Annex 1).

1 According to this framework, the MOUs define several aspects of cross-border cooperation, as follows: 1. Objectives 2. Specific areas of cooperation 3. Collaboration mechanism 4. Information sharing and confidentiality 5. Amendment, extension and termination 6. Dispute settlement 7. Entry into force of the agreement 4. Drafting Process Based on the headings outlined above, the TA consultants composed an initial draft of the MOU in English. This draft was shared with government counterparts in each country, that is, VAAC in Viet Nam, and PMU/CHAS in Lao PDR, as well as, where applicable, the respective Provincial Health Departments in each country. Government counterparts translated the drafts into Lao and Vietnamese, then reviewed the content and revised and expanded the content where necessary. On completion of the revisions, with TA 8204 facilitation, the drafts were exchanged between the two countries, and translations made into English. Government counterparts reviewed the drafts further, and additional revisions made as appropriate. Personnel with skills in Vietnamese, in PMU/CHAS, and Lao, in VAAC, aided the review process, ensuring that the wording of drafts in all three languages was consistent. 5. MOU Finalization Subsequently, the draft MOUs were presented at bilateral meetings, where participants from both countries were given an opportunity for further review and comment. Where facilities were available, copies were displayed in both languages, using dual LCD screens, so that participants from both countries could review content simultaneously. When consensus was reached on content, copies of the drafts were then printed and signed by representatives of respective agencies, at the same level of seniority. At the national level, a Deputy Director of CHAS, and a Deputy Director of VAAC signed the MOU between CHAS and VAAC. At the provincial level, Directors or Deputy Directors of Provincial Health Departments signed the MOUs. 6. Conclusions This was the first time, at either national or provincial level, that an MOU with a focus on HIV prevention have been signed between Lao PDR and Viet Nam. However, while establishing a solid basis for cooperation, it is important to bear in mind that, in and of themselves, MOUs, provide insufficient framework for joint cooperation. High‐level political commitment and support, seen for example in the key role played by the Viet Nam Deputy Minister for Health at the Ha Noi signing ceremony, is essential for success. Also, to be effective, MOUs need to be accompanied by concrete Joint Action Plans and annual workplans. For this reason, in planning, consideration needs to be given to scheduling of workshops or other follow‐up activities that will provide opportunities for these to be prepared. In addition, probably owing to the lead role taken by the health sector in their development, the MOUs developed to date focus mainly on the health sector. In both their development and scope, the involvement of key partners from other sectors has been limited. This may restrict the effectiveness of MOUs in addressing the needs of vulnerable populations in border areas. It is suggested that efforts are made in the MOU

2 development process to ensure that other relevant sectors, including civil society, are involved. Also, in general, the existing MOUs covering cross‐border cooperation between Viet Nam and Lao PDR tend to be rather broad in scope, without providing details of specific activities. This leaves certain areas and issues that need to be given further consideration in planning and implementation of joint activities. Some specific areas that remain ambiguous include: • Arrangements for cross‐border provision of VCT and referrals; • Cross‐border access to ART, methadone and other treatment and care services; • Arrangements for payment and source of funding for cross‐border services provided; • Disparities between, or lack of clear definitions in, the legal systems of the two countries, which may affect access to sex workers, PWID, and migrant workers. Such issues are challenging, at best, and may be difficult to address in the initial MOU process. However, with increased mutual understanding of the situation following experience in joint programming, both sides may be better equipped to identify solutions appropriate to the specific context, which can be incorporated into MOUs when agreements are reviewed. Last, some further important issues that need to be considered in implementation include:  JAPs need to be followed up closely and regularly, in order to ensure that activities are implemented, and done so in a way that is consistent with the wording and spirit of the MOU;  All contents of the national level MOU and JAP need to be reflected in provincial level MOUs and JAPs, to ensure the full participation and involvement of other sectors.

3 Annex 1: GMS Regional MOU At the regional GMS level, the key agreement is the Memorandum of Understanding (MOU) for Joint Action to Reduce HIV Vulnerability Related to Population Movement (renewed 2011). The MOU is an agreement between the six GMS countries: Cambodia, PRC China, Lao PDR, Myanmar, Thailand and Viet Nam. The MOU was signed originally in Cambodia in 2001, with a second MOU signed in 2004, which expired in 2009. The MOU represents a shared understanding among GMS countries that addressing HIV vulnerability, caused by the greater mobility of populations, is a common concern requiring concerted action. At the 9th GMS ADB Meeting of WGHRD in Guilin, the six GMS countries expressed a need to renew the MOU, which was confirmed in the 3rd GMS Workshop on HIV Prevention and Infrastructure in Vientiane in September 2010. In the Vientiane Meeting, ADB was requested to facilitate the process for renewing the 2004 MOU. ADB, the ASEAN Task Force on AIDS and JUNIMA convened a workshop with GMS countries in Bangkok (April 2011) to review and revise the MOU. The Bangkok Meeting resulted to a working draft of the MOU and Joint Action Plan and agreements on a 5‐year timeframe for a new MOU, which was signed at the GMS Summit in Myanmar in December 2011. The MOU has two main goals: i) to reduce HIV vulnerability; and ii) to promote access to prevention, treatment, care and support among migrants and mobile population and affected communities in countries in the GMS. Four areas of collaboration are outlined: 5. Promote improving policy environment and enabling mechanisms; 6. Promote community-based strategies that reduce HIV vulnerability; 7. Promote access to HIV and AIDS prevention, treatment, care and support; 8. Monitoring and evaluation. The JAP that accompanies the MOU was developed in consultations in 2012 in Bangkok and at the 11th Meeting of GMS WGHRD in Yangon, and a further meeting at the end of August 2013 in Bangkok. The JAP links each of the four areas of collaboration defined in the MOU to specific strategies and activities. The strategies and activities are as follows: Area 1: Promote improving policy environment and enabling mechanisms Strategy i): Support enabling policy environment to reduce HIV vulnerability, stigma & discrimination, and promote access to prevention, treatment, care and support by improving systems of governance on development‐related mobility. Activities: i) Collect evidence to support policy development and share information from research and good practices; ii) Raise awareness and advocate among policy makers for supportive policies; iii) Disseminate and advocate for the implementation of the MOU and JAP at various levels and among relevant sectors. Strategy ii) Strengthen intra‐ and inter‐country multi‐sectoral collaboration, including public‐private partnership, on HIV vulnerability related to migrants and mobile population at the local, national and regional levels. i) Facilitate multi-sectoral collaboration at intra- and inter-country levels relevant to mobility-related HIV issues. Area 2: Promote community‐based strategies that reduce HIV vulnerability Strategy i) Promote community‐based development approaches using people‐centered methodologies by empowering communities affected by development‐related mobility to prevent HIV infection.

4 Activities: i) Involve communities and key affected population and migrant workers in the planning, implementation and monitoring of interventions; ii) Develop and implement activities for affected communities to understand, anticipate and adjust to development factors that contribute to HIV vulnerability resulting from mobility; iii) Strengthen collaboration amongst agencies, including the private sector, involved in and related to development planning and projects/programs. Strategy ii) Enhance information dissemination, education and behaviour change communication in HIV/AIDS prevention for the community of migrants and mobile populations. i) Develop and implement localized, culturally-appropriate, target-specific behaviour change framework and plan. Area 3: Promote access to HIV and AIDS prevention, treatment, care and support Strategy i) Promote leadership and political commitment at the community, national and regional levels to improve access to prevention, treatment, care and support. Activities: i) Conduct dialogues between sending and receiving countries on access to prevention, treatment, care and support services for migrants and mobile population. Strategy ii) Support Strategies that ensure access to comprehensive HIV and AIDS prevention, treatment, care and support for migrant and mobile populations Activities: i) Develop a joint mechanism for provision of quality care, including ART and referral system for migrants and mobile population; ii) Develop joint programs for provision of prevention, care and support services for migrants and mobile population. Area 4: Monitoring and evaluation. Strategy i) Use the annual meetings of the focal points for monitoring the progress of the implementation of the MOU Action Plan. Activities: i) Review progress and identify follow up actions in annual meetings of focal points, held either independently or in conjunction with the annual meetings of ATFOA, JUNIMA, ADB, others. Strategy ii) Establish an M&E framework to review progress in the implementation of the MOU. Activities: i) Develop M&E tools in line with the activities of the Joint Action Plan; ii) Define M&E framework, baseline, indicators and assumptions for the MOU-JAP. Strategy iii) Establish reporting mechanism to the signatories of the MOU. Activities: i) Conduct Joint Review of progress in implementing the MOU; ii) Report to the biennial ASEAN Health Ministers Meeting plus China, or alternative meeting as required.

6 1. HIV and AIDS education personnel Government personnel at the provincial and district level bear the main responsibility as trainers and resource persons for HIV and AIDS and STI education and awareness raising activities. HIV and AIDS education staff work closely with key affected populations (KAPs), such as sex workers, and other populations such as migrants, who are vulnerable to HIV and STI infection. For this reason, because of the insights that they can provide from the lessons learnt and knowledge gained from their first-hand experience, as well as their on-going role and need for capacity-building support, the perspective of HIV and AIDS personnel is extremely valuable in understanding the local situation and for future planning. Ms. “Chanthamaly” is a government HIV educator from Attapeu province, aged 49 years, married, with a family. She is an ethnic Lao and was born in Vientiane province and completed Year 3 of lower secondary education. Chanthamaly came to Attapeu because she was posted to the province, where she now holds a deputy director position in a District Education Division, under the Ministry of Education. Around 2007 her office assigned her to coordinate with the Ministry of Health’s HIV prevention project on behalf of the Education Division, and she has now been involved with the project for about 4-5 years. Chanthamaly is now a member of the Attapeu Provincial Committee for the Control of AIDS (PCCA) as well the District Committee for Control of AIDS (DCCA) in the district where she works. In addition to her HIV prevention activities she is still responsible for carrying out her duties under her assignment with the Education Division. Chanthamaly has attended HIV and AIDS, and STI training workshops and subsequently became a trainer. She followed up and disseminated health education information to sex workers and also served as a trainer during the HIV and AIDS and STI workshops with them. In 2014, as she had a heavy workload from her other duties attending meetings in the province, Chanthamaly participated in HIV training activities for sex workers only twice. On both occasions she served as a trainer and shared the teaching duties in some sessions: “When they had HIV activities, they asked me to work with them. I can’t specify times, or what period. Every year, I have joined with them. Last year, I joined as usual but I can’t remember how many times. This year, I am very busy, so I have not joined regularly. When they have a training workshop, I am invited to help them as a trainer.” Chanthamaly thinks that these HIV prevention activities are very effective and necessary, because, firstly, it prevents the disease from spreading into the country from other places and, secondly, people with living with HIV infection don’t want to spread the disease to others: “We give them information. We don’t want people to get infected from others who have the disease, and we don’t want them to spread the disease to other people. This is very effective in helping people look after their health.” She has also been involved in gathering of information on sex workers through visits to the establishments where they work. On the last occasion, she joined the Central and Provincial team to gather information from migrant and mobile workers. After gathering information they disseminated health education material. They also disseminated HIV education material to migrant workers at Km 52 in Samakysay District, and in border areas with Viet Nam. Also, they disseminated health education information to Vietnamese girls providing services at bars and restaurants in the provincial town area. Based on interviews with some of the

1 girls after these sessions, Chanthamaly feels that the sessions were of benefit to them, as their knowledge on HIV and STIs increased, and they could correctly answer the questions asked during the interviews. In regard to the main challenges faced in providing HIV education to migrant workers, Chanthamaly identified a number of important issues. Difficulty in access and coverage remain major challenges, because there are increasing numbers of workers employed by companies on the rubber tree plantations and in various other enterprises. If possible, it is best to go and disseminate HIV and STI prevention information in each settlement or camp area; management can assemble the workers together so that it is easier for educators to provide information. However, when the settlements are spread out across a wide area, it is difficult for the government sector, in particular the PCCA, to provide support for organisation of education activities or visits by resource persons to disseminate information to each and every area. Another challenge is that, these days, most workers are teenagers. Many migrant workers have no vocational training, and have completed only Year 12 of their secondary education before coming to work. HIV educators don’t know how much prior knowledge they have about issues such as HIV and AIDS, and it is difficult to assess them because of challenges in access. Based on the monitoring of sex workers who participated in HIV and STI education, Chanthamaly has observed significant changes in their behaviour. Trainees are more conscious of the need for protection, and have high-self prevention awareness. Following the last counselling or training they provided for workers in each establishment, the girls passed on the knowledge to their friends as well, in particular the need to use condoms with their clients. When they finished the condoms provided to them during the training sessions, they called the trainers to ask for more condoms. Another significant change was to encourage sex workers to use condoms when having sex with their boyfriends, and help them understand that as long as they are not married, it is necessary to use condoms every time they have sex. The girls also volunteered for blood tests if they had been involved in any behaviour they thought put them at risk of infection. The more people who attended training workshops, the more requests were received for blood tests, and the more recruits volunteered to attend further training sessions, so that from only a few participants in early sessions, the number grew to over 10 people in later workshops. This indicates that the girls were sensible in their approach, and once they understood its importance, they wanted to learn more about prevention. The education sessions have also had a positive impact on use of care and treatment services. Previously the girls used to go to private clinics or pharmacies to get help when they had health problems, but now they mostly consult qualified doctors. Also, after the training sessions the sex workers at the entertainment places now have the telephone numbers of the health personnel: “After the training, they call to ask us ‘We have this symptom, what is it and how did we get it?’ Every time they call us, we suggest them to go to see a doctor who could provide counselling or organise a blood test. We don’t want them going to buy medicines by themselves at the shops.” There were several challenges encountered in presentation of training sessions for sex workers. Some girls were sleepy, hung over, didn’t want to get up, or woke up late, which affected their participation. Also, some shop owners didn’t attend sessions, or cooperate fully. Chanthamaly said that, because they brought their girls for training, the shop owners were concerned that they would lose income. This was another reason why they were unable to access all the girls working in entertainment venues. This didn’t apply just to migrant workers, but even local people.

2 Although she has been involved in activities supported under previous ADB projects, Chanthamaly doesn’t know much about the new ADB-supported HIV project. However she feels that support for capacity building, training, supervision, management and other areas related to HIV and AIDS activities is necessary and will be of benefit. “I used to participate with ADB the first time they came. I helped them as a trainer. They helped about migrant workers, particularly bridge and road construction workers, but I’m not sure whether this project was from ADB or NCA because I was a coordinator from another sector.” Chanthamaly says she has gained a lot of knowledge from her involvement as a trainer in the implementation of the HIV and AIDS project, and she is thankful that she became involved. Mainly, she has learnt about HIV and AIDS, where it comes from, what the symptoms are, and how HIV is spread, and has been able to help pass this on to others: “I didn’t know more than the doctors. I just provided some information on counselling to sex workers. However, afterwards many people called me “doctor”, but I told them “No, I’m not a doctor”. Chanthamaly feels that, for HIV education to be truly effective, its very important that sex workers and migrants learn about HIV through “face to face” activities such as training workshops, rather than only from mass media and other communication methods. Also, small groups are much better than large groups: if activities are conducted in a short time frame, with a large group of people, then the information provided is superficial and not absorbed properly. Small group sessions, organised as quiz activities or simply as provision of health education information face to face with a group, is much better-received and appreciated by participants. As a professional educator, Chanthamaly also feels that there should be an increased focus on the education sector and organisation of HIV and STI prevention and awareness activities in schools. Increased attention needs to be paid to education of adolescents, within the school system as well as out of school. The case of Ms. Chanthamaly helps illustrate several key issues regarding the target population in Attapeu, as well as highlighting some of the challenges, and directions for effective future programming. From her account, it is clear that there is a wealth of experience and understanding of the situation among personnel involved in HIV and AIDS and STI education at the provincial level, which provides a valuable resource. At the same time, this body of knowledge and experience may not be used to best advantage owing to heavy demands on the time of personnel. Ways need to be found to use resources such as Ms. Chanthamaly as effectively as possible, for example as trainers of trainers. Activities with some key populations, in particular sex workers, appear to have been implemented well, with good effect and appreciation by the beneficiaries. The higher effectiveness of “face-to-face” activities, possibly complemented by IEC and mass media, is a key point for note in design of future programs. Activities with migrants have been fewer in number, and while the approach used with sex workers may also be effective, there appear to be different challenges, in particular difficulty in access, that need to be addressed. The changing nature of the migrant population, with an apparent shift to lower education levels, may also present challenges and require development of more innovative approaches.

3 2. Vietnamese migrant worker in Lao PDR There are an estimated 10,000 Vietnamese migrant workers in Attapeu Province, Lao PDR. Most of these workers are men employed by large Vietnamese companies such as Hoang Anh Gia Lai undertaking construction projects or engaged in agriculture enterprises or logging operations in Lao PDR. While the work involves spending long periods of time away from their families, living conditions can be rough, and access to services is limited, the financial incentive is strong and workers can earn a good income. Restaurants and small drink shops or karaoke bars situated close to camps or workers’ housing provide entertainment for those who are lonely or are in need of relaxation. However, as this case study shows, vulnerability to HIV and STI is complex; assumptions that all migrant workers engage in sex may be incorrect, but at the same time, should sexual encounters take place, lack of detailed knowledge on how to use condoms for protection, or where to obtain condoms or access VCT services, may put migrant workers at increased risk. “Duc” (not his real name), aged thirty-one and single, works on one of Hoang Anh Gia Lai’s rubber plantations, located in Saysettha District, located some 40 km from the Attapeu provincial centre. He is a lowland Vietnamese, from Chu Pah district, Gia Lai province, in the central highlands region of Vietnam. Duc completed his education in Viet Nam, graduating in economics, but owing to the lack of positions in Viet Nam, he decided to seek work in Laos, where there is work, job opportunities, higher salary and better employment conditions. He has been working in Laos since 2009 with the Hoang Anh Company, with whom he holds a permanent position overseeing rubber tree harvesters. Duc lives in a dormitory for workers on the rubber plantation and works full-time, starting work every day at 8 am and working until 4 pm. Under his contract, if the company asks him to work early morning or evening shifts, Duc has to go to work as required, however he is then eligible for getting flexi-days off work. He has four days off every month. Every two months, Duc goes across the border to visit his home. Between visits home, he usually calls his family at least once every week; sometimes he calls home every day, and sometimes his family calls him. The company has provided Duc and other workers with a Unitel phone card. There are a number of restaurants and drinking places located a short distance from the camp with girls working as waitresses and hostesses who sometimes agree to sleep with customers. Duc and his friends sometimes go to these places to relax. But Duc just has a few drinks and talks to his friends. He doesn’t play around with any of the girls. He says he’s never had sex. However Duc is aware of condoms, that they can prevent HIV transmission, and of the need for self-protection: “I don’t know clearly but my understanding is if using condoms ensure us safety from HIV/AIDS transmission and it can be prevented from other diseases.” “If I did go out to play around, I would have to use condoms when having sex. I have never had sex yet and I don’t know how to use condoms.” Duc learned about the use of condoms for protection during sex intercourse from watching TV and through advertisements, but this information wasn’t detailed. He knows that HIV can be transmitted through blood contact with blood, sharing the same needles with infected persons, and through having sex. But Duc doesn’t know how to apply a condom, and while he knows in general that condoms can be obtained from the district hospital and shops, he doesn’t know exactly where he could get a condom in the area near the camp, and how much he would have to pay.

1 According to Duc, drug use is not common among the migrant workers in his camp. Duc doesn’t know of anyone who uses drugs. If he did hear about anyone using drugs he would tell the person to stop, and if they didn’t want to stop, he would call the management to come here and help in order to keep this place drug-free. “I will help my friends and other people not to use drugs and if they have sex, they should use condoms with their partners to be safe.” Duc has never participated in any HIV and AIDS awareness activities. So far no organisations or sectors have come to disseminate HIV information and IEC materials in his workplace at Hoang Anh rubber tree plantation but he is not sure whether there have been any activities at other places. In any case, according to Duc, he is not sure of the value of participating in a condom demonstration as he has never had sex. Duc has never been for a blood test, and he doesn’t know where he could go to have one done outside the company: “I don’t have any health issues and my health is good, so I don’t go to test a blood because my physical condition is still good. If I want to have a blood test, I would go to test at the company clinic.” Duc thinks that there should be more education and awareness activities for migrant workers. IEC communication such as talking about HIV, showing of pictures and explaining each one would be very helpful. Also, HIV text messages through the mobile phone system would help increase knowledge and awareness on HIV prevention. He is happy to attend HIV project activities if the company gives him permission, and if HIV team wants to come to disseminate information, there is no problem as long as the official paperwork is completed in advance to inform them, so they can inform the workers when they should assemble, or arrangements made for workers to be brought in, and a suitable place found for the activities to be held. This brief case study provides a number of insights into the situation of Vietnamese migrant workers in Lao PDR, their risk behaviour, knowledge of HIV and AIDS, access to services, and interest in opportunities to improve their knowledge of HIV and AIDS and protect themselves from HIV and STIs. “Duc” may not be typical of most Vietnamese migrant workers in Attapeu: he is relatively well-educated, with a higher degree, occupies a supervisory position, and is sexually inexperienced. However, his case does illustrate well the fact that the situation of migrant workers differs widely, and it is unwise to generalize. Further, despite his education and lack of sexual experience, there are clearly opportunities for contact with sex workers, and should he happen to engage in sexual contact, his lack of knowledge and practical skills in the use of condoms, and where to obtain them, may put him at risk of infection. From Duc’s account, there are also several positive pieces of information from the point of view of HIV and AIDS programmers: Duc appears to be highly receptive to opportunities for HIV and AIDS and STI education; also it appears that the company he works for is very open to the organization of training sessions on HIV and AIDS for its employees. In addition, migrant workers appear to have easy access to mobile phone networks, which would open opportunities for the introduction of innovative approaches for HIV IEC, such as mHealth.

2 3. Long haul truck driver Long haul truck drivers are a group that has long been identified as having a high vulnerability to HIV infection, owing to opportunities for sexual contact with multiple partners, as well as drug use, in particular amphetamines, coupled with a lack of access to VCT services. With the opening of the economic corridor and the rapid development in cross-border trade and transport between Attapeu province in Lao PDR and Kontum province in Viet Nam, the number of long-haul truck drivers has increased dramatically. For this reason it is important to understand more about the situation of long-haul truck drivers, their risk behavior, knowledge about HIV and AIDS and STIs, and their access to services for prevention, diagnosis and treatment. “Linh” is a Vietnamese male truck driver who hauls logs between Saysettha District, Attapeu and Kontum province, Viet Nam. Linh was born in Phu Yen province, on Viet Nam’s south central coast, and he is 45 years old, married with two children, a daughter and a son, The family now live in Binh Dinh province, also on the south central coast. Linh completed year 6 of lower secondary school and has been driving for 20 years. The salary is not high, but he does this work because of the lack of jobs in his home province. The work conditions, with lump-sum payment, also mean that he is free to work anywhere and choose his own hours. “I drive through the Route No. 40 via Phu Keua Lao-Vietnamese check point crossing the border to Attapeu province every time. Once a month, I drive across the border. But it depends on work. Sometimes I come today and then tomorrow I drive back across the border. Every time, I stay about 10 days. I drive alone. I sleep in the truck. If the truck stops somewhere, I sleep in that place. For example, if the truck stops at the border, I will sleep there.” Linh says he has never been to any of the entertainment places along the route he travels, either in Laos or Viet Nam. He would like to go out to bars, but doesn’t have enough money. He has sex at home with his, and doesn’t have any other partners. He doesn’t have sex with men. He has never used condoms and doesn’t know where to get them. “If I stay with my wife, it is not necessary to use condoms. If I went out to play with another girl, I would use a condom.” As far as Linh knows, none of his close truck driving friends use drugs, however he knows of some drivers who take or inject drugs, mostly amphetamines (ya ba). The Viet Nam law is very strict on drug use, and the harsh penalties discourage use of drugs amongst people such as truck drivers who provide easy targets for law enforcement officers. If he learned that any of his friends were using drugs, Linh says he would try and discourage them: “If there are other people, not drivers, using drugs, I would tell them to stop. I don’t want my friends and other people playing around, they should have a single partner.” Linh has some basic knowledge on HIV and how it can be transmitted. He knows that HIV can be acquired through sexual contact, and that condoms can prevent infection. He also knows that HIV can be transmitted through contact with blood. For this reason, even though his health is good, he has regular blood tests for HIV, because he often goes to Vietnamese barber shops, and he is afraid that cutting his hair and shaving, with occasional bleeding from cuts and abrasions, might lead to HIV infection. Linh doesn’t know where he would go for a blood test or advice in Laos; he prefers to have blood tests for HIV at hospitals in Viet Nam. He has been to a hospital clinic in Binh Dinh province, where he lives, and once a year he goes to Ho Chi

1 Minh City to have a blood test for HIV. The last time was in July, 2014. He receives the result from the physician doing the blood test straight away. He thinks that if someone gets a positive result, they should not drive trucks. He doesn’t know where to test in Laos because he spends most of his time driving, and stays in the country only a short time. Linh obtained most of his knowledge about HIV from information he has read about HIV and AIDS. He has previously attended one training session on HIV, organized in his home province, Binh Dinh, in 2012. Since then he has not attended any other HIV education sessions. As far as he knows, there have never been any training sessions on HIV and AIDS, or how to use condoms properly, organized by agencies or organizations for him and other truck drivers. Over the last 6 months, however, he has heard HIV and AIDS information quite often from loud speakers, radio and TV as well as receiving IEC materials on HIV and AIDS prevention (e.g. pamphlets) along the truck routes he uses. Also, HIV prevention officers came through the villages and distributed condoms to each household. Linh has a mobile phone, and he likes the idea of receiving text messages on HIV and other health subjects, which would be convenient and help him learn more. “Linh”’s may not be a typical case – only a rigorous study would determine this – but his story does provide some interesting and important information that can be used in further programming. From his own account, Linh does not seem to have any risk behavior for HIV transmission; he does not have multiple sexual partners, and he does not take drugs. Clearly, however, opportunities exist for both types of risk behaviour, and Linh’s truck-driving friends may engage in these activities. Linh appears to have been fortunate in accessing basic information on HIV and AIDS, which he has followed, even to the point of being over-concerned regarding the risk of HIV transmission from his visits to the barber. This reflects positively on the effectiveness of HIV and AIDS education activities, and service provision, in Viet Nam. However, once they cross the border, it is apparent that members of mobile populations, such as Linh, do not have access to prevention messages or information on available services while they are in the Lao PDR. There may be several reasons for this, including the nature of their stay, which is often of short duration, and the fact that IEC information is not available in Vietnamese language. Also important is the fact that Linh, in common with migrant workers and other mobile populations, carries a mobile phone and would welcome messages on HIV and other health issues.

2 4. Lao owner of entertainment place Business owners and managers are the gatekeepers for HIV and AIDS prevention activities with vulnerable migrant workers. Not only is their cooperation necessary for access to workers and clients, they have a long-term commitment to their business, and fulfil an important support role with workers. For this reason they serve as an important source of information on HIV and AIDS and STIs, as well as helping in distribution of condoms and referral to VCT and other services.

“Auntie May” runs the “Champa” bar, a small drinking shop in Samakysay District, Attapeu Province, Lao PDR. She is an ethnic Lao, from Champassak province (adjacent to Attapeu) and completed Year 1 of her secondary education. Auntie May has been operating drinking shops for around three years. She established the current business just over a year ago. There are 15 girls working in her shop, but, as Auntie May is careful to explain, she doesn’t employ the girls, but they can get money from each table where they sit and serve customers. Auntie May simply provides the girls with meals and accommodation.

Most of the girls working in the shop at present are from Phonhong district, Vientiane province, with some from Pakse District, in Champassak province. Most of them are ethnic Lao. They are aged between 19 and 20 years of age. The length of time each girl stays varies; some only stay a short time before returning home, and some stay longer. Some stay for over 1 year, and others stay for just a few months, go back home for a while, then come back to the shop again. So the girls at the shop include both newcomers as well as old hands.

The clients at this drinking shop are mostly Lao nationals, many of them civil servants, including forest, health, and other government officers. There are also businessmen. There aren’t many Vietnamese. Some customers come two or three times a week, while some are rarely seen, coming only once in 3-4 months or so. Some customers just drink and listen to songs, and some like to have sex with the girls:

“Mostly they come to get girls. If they don’t see girls, they won’t sit and stay. Clients and girls can negotiate together. If a client takes a girl out of the shop, he will pay about 50,000 kip (approx. USD 6) to the owner.”

Auntie May says that the girls know about the need for HIV/AIDS/STI prevention and how to go about it, and that mostly they use condoms with clients:

“I told and explained about HIV to the girls that ‘If you have sex with clients, you have to use condoms to look after your health’. When we told them, they knew it already. When they go with clients, they bring condoms as always.”

According to Auntie May, condoms are always available. Condoms are available for distribution through the HIV section at the district health office, so if they want condoms, they are able to go and get some there. When supplies are finished, they simply go and ask for more. Because they are available free, the shop distributes the condoms free to the girls, so they don’t have to pay. However, condoms are also easy to find for sale in nearby stores, so access is not a problem.

Auntie May says that none of the girls working at her shop have symptoms of STIs. However, whenever they do get sick, they go to the provincial armed forces hospital. She says the girls are not scared of going for check-ups at the hospital. VCT and other services are available in the district, with blood tests provided

1 at the hospital or private clinics. However the shop doesn’t become involved in referrals for check-ups, and its left up to the girls to make their own arrangements:

“I don’t see girls going to use the services of blood test or get advice when they are sick. I don’t see them going for check ups. But I know they go for check ups even though they look healthy. They know well how to prevent [HIV and STIs]. If a girl wanted to go to for a blood test, it would not be difficult.”

According to Auntie May there are HIV and AIDS and STI prevention activities being conducted in Attapeu, under which health workers visit the drinking shop regularly and organise meetings with the girls, in order to talk to them about HIV and AIDS prevention and distribute booklets for them to read. Each time they come, they explain to the girls the need for prevention of HIV and STI infection and how to protect themselves and their clients. The visits are welcomed, and whenever there is an HIV meeting, the girls are free to attend. Auntie May thinks that it is a good thing that health staff come and talk to the girls, however she prefers that such visits are done on Saturday and Sunday mornings, which is a more convenient time for the girls and shop owners, as there are no clients then.

In regard to the ADB project, Auntie May said that she had heard something about a new project in the province, but didn’t know anything about the planned project activities, or who was involved. In previous HIV prevention activities, while the girls got involved with training, she didn’t get involved with any of the training sessions organised for shop owners. However, her husband attended an HIV prevention workshop on behalf of the shop.

Auntie May emphasised the need for HIV education to be provided to the girls by qualified trainers. While she knows enough to talk to the girls about the basic facts on HIV and AIDS, she feels this is not good enough, and some of the girls don’t understand and gain the detailed knowledge that she thinks is necessary for them to prevent infection:

“I would just like them to come to train the girls. I can talk about HIV but it is not good enough. Some girls don’t understand and know deeply. I know about HIV but I don’t know more than officers. “

The case of Auntie May provides an interesting illustration of the situation in a bar where sexual services are available, as well as the owner’s perspective, and some of the strengths and challenges faced by the HIV and AIDS program in Attapeu. From this account it seems that while owners may depend on the girls to attract customers and encourage the sale of alcohol, and are happy for the girls to make arrangements for sex with customers, their commitment to ensuring the girls’ health is rather passive, being limited to providing information on HIV and STIs, making condoms available, and allowing health personnel to conduct training sessions with the girls. The owners, at least in this case, don’t appear to insist on girls undergoing regular check-ups, or making arrangements for these to be carried out. It is, however, encouraging to know that the girls, and owners, are receiving information on HIV and AIDS and STIs, and condoms, the girls are able to access services for health checks and blood tests, and the owners appear to have a highly positive attitude towards provision of training on HIV and AIDS for the girls.