Myanmar's AIDS strategy: treat only the sickest

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 It's hard to say for sure how Kyaw Lin's battle with HIV/AIDS would have gone had doctors here been able to give him the medicine he needed earlier. But it's difficult to imagine it could have been much worse.

 Mr. Kyaw Lin, a factory worker from small-town Myanmar, was diagnosed with HIV four months ago. His family, suddenly reviled and isolated in their hometown, hired a car for the four-hour drive to Rangoon, the only real metropolis in this impoverished country, where they'd heard there were people who knew how to treat the virus that levelled the 33-year-old in his prime.
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 They found doctors from Médecins Sans Frontières in Rangoon who knew what Mr. Kyaw Lin needed: antiretroviral medicines which slow the progression of symptoms, now in use worldwide to treat AIDS sufferers. But in Myanmar (formerly known as Burma) there aren't enough antiretroviral medications to deal with an AIDS crisis that continues to grow, in large part because of the country's imposed isolation from the outside world.

 While Mr. Kyaw Lin was clearly ill and in need of drugs when he arrived in Rangoon last fall, his CD4 count - a test used to measure the strength of the immune system that HIV attacks - wasn't low enough to qualify for a course of the limited number of antiretroviral drugs available. Instead, he was told to go home and come back when the disease had progressed.

 Now he is far, far sicker. By the time Mr. Kyaw Lin began his antiretrovirals on Jan. 19, he was suffering from an undiagnosed brain illness that leaves him silent and staring for much of the day, except for the occasional burst of unsettling laughter. His skin is covered in sores that he scratches at with a blue comb while his mother and sister - who have moved with him into a bare-bones shelter for AIDS patients on the outskirts of Rangoon - look on with evident worry.

 "We didn't have adequate medications for everyone. Even though he needed ARVs, he needed to wait - we only have enough for those who need critical treatment," explained a social worker at the shelter where Mr. Kyaw Lin and his family are staying, sleeping on straw mats in a room filled with three other AIDS sufferers and their families.

 When it comes to HIV/AIDS, Myanmar is doubly cursed. At a time when worldwide infection rates are slowing, and in many cases falling, front-line workers here are still overwhelmed by new patients who come in every day, often collapsing as they reach the clinics at the end of long overland or river journeys from small villages in the country's poorly connected regions. Many had never heard of HIV until their doctor told them they were infected with it.

 While Myanmar's AIDS crisis is not yet of the scale that some countries in Africa are facing, the country lags far behind in its ability to deal with the spread of the epidemic. International aid organizations estimate there are some 242,000 people (or just under 1 per cent of the adult population) with HIV, of whom as many as 120,000 currently need antiretroviral treatment. But there's medicine for only 20,000.

 That access rate is believed to be the worst in the world, a crisis even when compared with sub-Saharan Africa, where after years of neglect even the region's poorest countries are now able to provide antiretrovirals to upward of 50 per cent of their AIDS sufferers.

 In Rangoon (also known as Yangon), there are international aid organizations present and therefore some hope of receiving treatment, though it sometimes comes too late. In the farther-flung corners of the country - particularly the areas near Myanmar's borders with Thailand and China, where fighting regularly flares between the army and ethnic militias opposed to the junta - the only option is often a cash-strapped government hospital with no access to modern HIV/AIDS medicines. (AIDS-related illnesses are the country's second biggest killer, after malaria.)

 The shortages mean that only those with a CD4 count of less than 200 are eligible to receive antiretroviral medications from MSF and the other groups distributing them. By that point, it's often too late as the immune system has been ravaged to the point that the sufferer is easy prey for tuberculosis and other diseases. The World Health Organization recommends that anyone with a CD4 count of less than 350 should receive antiretrovirals.

 Those helping fight Myanmar's AIDS crisis split their anger between Myanmar's military government and what some call an informal international ban on aid to Myanmar that has left humanitarian workers short of cash and hamstrung by impractical restrictions that forbid them from having any contact with the same Ministry of Health they're trying to support.

 "The government's health budget is much too low, and the amount of foreign assistance is much too low," said Andrew Kirkwood, country director for Save the Children. "Should the international community punish the people who need ARVs just because their government is not spending enough on health? To me, that's a very perverse conclusion to make."

 It's not just antiretrovirals that are lacking. At an informal shelter run by the Phoenix Association, a small and independent charity run by volunteers, there's no money for even the most basic supplies for the two dozen people currently in their care.

 "We don't have enough mosquito nets, pillows or mattresses. We can't even provide our patients with food. They have to buy their own and cook for themselves," said Thiha Kyaing, founder of the Phoenix Association.

 To illustrate the toll the lack of funding takes, he pulls out the records book for the Phoenix shelter on the edge of Rangoon. The numbers for 2010 were grim: 202 patients received, 60 funerals. "People die every day because of the criteria [for receiving antiretroviral medication]," said Mr. Thiha Kyaing, his soft voice barely audible as an infected two-year-old boy in the same room wails from a high fever.

 Speeding the epidemic's spread is widespread ignorance in Myanmar about the virus, especially beyond Rangoon. Particularly vulnerable is the country's vast community of sex workers, who often work in anonymous massage parlours and "beauty salons" off the radar and beyond the reach of the few trying to spread the message about condoms and disposable needles.

 Those who contract HIV-AIDS find themselves isolated and alone. Among the patients at the Phoenix shelter are a husband and wife who are expecting a baby any week now. The 24-year-old husband was immediately dismissed from his post as a soldier in Myanmar's army when his commanding officer found out he had contracted HIV, likely from a hospital blood transfusion. "They were afraid he would infect the whole regiment," his 24-year-old wife said. The couple will now have to raise their child on his military pension of $9 a month.

 There is some hope on the horizon. After prolonged negotiations, the Global Fund to Fight Aids, Tuberculosis and Malaria entered Myanmar in early 2011 with a budget of $105-million (with tighter than usual monitoring because of corruption concerns). But even that injection of money - which will be spent on education and prevention as well as treatments - will be far from enough. Even if the Global Fund achieves its own goals for distributing antiretrovirals, the number of HIV/AIDS sufferers receiving the treatment will still be less than 50 per cent.

 For the Global Fund, it's the second try at tackling Myanmar's HIV/AIDS crisis. The fund withdrew from the country in 2005, citing government restrictions that impeded its ability to monitor how grant money was being used.

 "The international community, particularly the folks working on HIV/AIDS, are frustrated with the lost time [because of the 2005 pullout]," said Elmar Vinh-Thomas, regional team leader for Asia and the Pacific at the Global Fund. "The funding gap in Myanmar is growing because the disease burden is growing."


Orgnization: Médecins Sans Frontières Phoenix Association