FY 2015 Burma Country Operational Plan (COP) The following elements included in this document, in addition to “Budget and Target Reports” posted separately on www.PEPFAR.gov, reflect the approved FY 2015 COP for Burma. 1) FY 2015 COP Strategic Development Summary (SDS) narrative communicates the epidemiologic and country/regional context; methods used for programmatic design; findings of integrated data analysis; and strategic direction for the investments and programs. Note that PEPFAR summary targets discussed within the SDS were accurate as of COP approval and may have been adjusted as site- specific targets were finalized. See the “COP 15 Targets by Subnational Unit” sheets that follow for final approved targets. 2) COP 15 Targets by Subnational Unit includes approved COP 15 targets (targets to be achieved by September 30, 2016). As noted, these may differ from targets embedded within the SDS narrative document and reflect final approved targets. Approved FY 2015 COP budgets by mechanism and program area, and summary targets are posted as a separate document on www.PEPFAR.gov in the “FY 2015 Country Operational Plan Budget and Target Report.” Burma Country Operational Plan (COP) 2015 Strategic Direction Summary August 12, 2015 Table of Contents Goal Statement 1.0 Epidemic, Response, and Program Context 1.1 Summary statistics, disease burden and epidemic profile 1.2 Investment profile 1.3 Sustainability Profile 1.4 Alignment of PEPFAR investments geographically to burden of disease 1.5 Stakeholder engagement 2.0 Core, near-core and non-core activities for operating cycle 3.0 Geographic and population prioritization 4.0 Program Activities for Epidemic Control in Priority Locations and Populations 4.1 Targets for priority locations and populations 4.2 Priority population prevention 4.3 Voluntary medical male circumcision (VMMC) 4.4 Preventing mother-to-child transmission (PMTCT) 4.5 HIV testing and counseling (HTC) 4.6 Facility and community-based care and support 4.7 TB/HIV 4.8 Adult treatment 4.9 Pediatric Treatment 4.10 OVC 5.0 Program Activities to Sustain Support in Other Locations and Populations 5.1 Sustained package of services and expected volume in other locations and populations 5.2 Transition plans for redirecting PEPFAR support to priority locations and populations 6.0 Program Support Necessary to Achieve Sustained Epidemic Control 6.1 Laboratory strengthening 6.2 Strategic information (SI) 6.3 Health system strengthening (HSS) – clear linkages to program 7.0 USG Management, Operations and Staffing Plan to Achieve Stated Goals Appendix A- Core, Near-core, Non-core Matrix Appendix B- Budget Profile and Resource Projections Appendix C- Sustainability Analysis Dashboard Appendix D- Key Components of Mechanisms providing Technical Assistance (TA) and Support at Site Level Appendix E- Location and Number of Medication Assisted Therapy (MAT) Sites 2 | P a g e Version 6.0 Goal Statement The PEPFAR Burma team’s over-arching vision is to support Burma to achieve its goal of epidemic control applying the “90-90-90” global targets as a framework for HIV program planning and prioritization. PEPFAR support in Burma will focus on technical assistance (TA) and targeted support to improve the cascade of HIV prevention, testing and treatment services, for key populations affected by high HIV prevalence, limited access and low coverage of HIV services. The 2015 Burma Country Operation Plan (COP) 2015 reflects the catalytic and informative role the PEPFAR Burma team is taking in supporting the Government of Burma (GoB) deliver on the goals of their National Strategic plan, namely in achieving high rates of HIV testing among key populations with early enrollment and high rates of retention in treatment services. To achieve this, PEPFAR Burma has identified four priority catchment areas based on the best available epidemiologic and other data and will support approximately 36 community sites providing prevention, care and treatment services. In addition, PEPFAR Burma will provide technical assistance to the public health care sector for rollout of decentralized Anti-Retroviral Treatment (ART) services, including improved access and retention for Key Populations (KP). To accomplish this, PEPFAR Burma will continue and enhance close collaboration with all key in- country actors including the Government of Burma, civil society, the Global Fund (GF) and other stakeholders to leverage available resources and help direct efforts to towards epidemic control. PEPFAR Burma is in a unique position to adapt its role in a country that is re-defining itself. In 2015 Burma will hold national elections that may re-set the government systems that have come before it. Over the coming year, PEPFAR will work closely with partners in government, civil society and the private sector to best position itself to strategically support the National AIDS Program (NAP) and civil society partners to significantly scale-up HIV testing and treatment services. PEPFAR will provide technical assistance to develop operational guidelines, protocols and strategies that are guided by national and international evidence and assist in developing laboratory and supply systems to sustain the program in the long-term. In the second year of expansion of PEPFAR support, building on efforts started in 2014, the team aims to improve the cascade of HIV services for Female Sex Workers (FSW) and Men who have Sex with Men (MSM), increasing the focus on HIV testing and counseling with aggressive provision for immediate ART in those who are HIV infected across community-, private and public sector sites within the 4 catchment areas, as well as providing technical support to strengthen and improve strategic planning, implementation and monitoring for HIV treatment services in the national program. PEPFAR Burma will begin to engage in TA and support for services for People Who Inject Drugs (PWID) in the northern states of Kachin and Shan where HIV prevalence in this key population is highest and programs operate in a particularly complex environment that affects access to and establishment of quality health and HIV services. The GoB and multi-lateral organizations (WHO, UNAIDS, GF) have requested both long term and short term TA from PEPFAR and are receptive to US Government (USG) recommendations. Through these partnerships PEPFAR will contribute to improve data collection, use and coordination for optimal program impact. 3 | P a g e Version 6.0 1.0 Epidemic, Response, and Program Context 1.1 Summary statistics, disease burden and country or regional profile Burma, a sovereign nation bordered by Bangladesh, China, India, Laos, and Thailand, is made up of 15 states, 69 districts, 330 townships, and 13,276 villages. It has a population of 51,419,420 million and comprises 138 ethnic groups – 89% of whom are Buddhist. A military dictatorship controlled Burma’s government for over five decades, but relinquished control in 2011. The GNI per capita in Burma in 2013 was US dollars (USD) 1182.6, ranked 174th in the world. The WHO reports that total expenditure on health, as a percentage of GDP (2012), is at 1.8%. According to NAP Anti-Retroviral Treatment (ART) program data, at the end of 2014, 85,257 persons were receiving ART. This represented around 55.5% of all those in need of treatment as specified in 2014 revised national treatment guidelines which support initiation at CD4 500 threshold. The national program has set an ambitious treatment target of 106,058 as the target for ART by the end of 2016 (a 25% increase in less than two years)1. However, supply chain and laboratory systems supporting ART scale up are not well-developed, and regular monitoring of results at all levels does not routinely occur. PEPFAR will provide technical support to improve the quality of HIV care and treatment services, as well as enhance strategies for effective decentralization working with the NAP as well as implementing partners. Based on modeling and estimates established for HIV in Burma, 0.5% of adults, and 0.7% of pregnant women are HIV infected, with substantially higher HIV prevalence among FSW (8.1%)2, MSM (10.4%)2 and PWID (27.0%)3. An overall decreasing trend in prevalence has been reported among key populations over the last five years, although the quality of data is uncertain, and the decreasing trends may in part be due to high mortality rather than declining incidence. For example, the most recent estimates of HIV prevalence among PWID (27%) based on 2014 IBBS findings are substantially higher than reported in the NAP progress report which used HSS and HIV sentinel surveillance data. In addition, there is limited information at sub-national levels and the results do not include the large parts of the country where there is ongoing civil unrest. Keeping in mind limitations in data quality, Figure 1 below shows trends in HIV prevalence between 2007 and 2012, with prevalence remaining highest among PWID. In addition, prevalence appears to be increasing in the MSM population which will inform a prioritization of programming in COP15 to respond to key MSM prevention and treatment needs. In addition to high prevalence among KP, it points to the need for HIV screening and treatment among patients with Tuberculosis (TB) and Sexually Transmitted Infections (STI) where there is likely an overlap in risk behaviors. HIV Sentinel Surveillance (HSS) is conducted annually, with data reported from around 35 townships. 1 Global AIDS Progress Report for 2012-2013, Myanmar, National AIDS Program (NAP), 31 March 2014 2 NAP HIV Sentinel Sero-Surveillance, 2013 3 Preliminary PWID Integrated Bio-Behavioral Survey (IBBS) Findings, 2014 4 | P a g e Version 6.0 Figure 1: Trends in HIV Prevalence in Sentinel Populations, 2007-2012 40 35 30 PWID FSW 25 MSM 20 Male STI Patients 15 Pregnant Women 10 New Military Recruits New TB Patients 5 0 2007 2008 2009 2010 2011 2012 2013 Currently available key population (KP) size estimates are 70,000 for FSW2 and 230,000 for MSM2.