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AN HIV-positive woman receives medicine through an intravenous drip at
Medecins Sans Frontieres-Holland (AZG)’s clinic in Rangoon last year.
(Photo: Reuters) |
The biggest provider of HIV drugs in Burma has welcomed
recommendations by the World Health Organization (WHO) to begin
treatment at a much earlier stage of the disease, but says the country’s
health care providers do not yet have the capacity to follow the new
guidelines and must routinely turn away sick patients due to
underfunding.
The WHO has changed its global guidelines for HIV treatment, issuing
new recommendations over the weekend that call on countries worldwide to
begin antiretroviral therapy (ART) earlier, when the patient’s immune
system is stronger. The new guidelines make about 26 million people in
poor and middle-income countries eligible for the drugs, compared with
17 million previously.
In Burma, however, health care providers say the new guidelines—while
welcomed—will likely have little effect on the ground, as clinics
already struggle to treat the volume of patients recommended by the old
guidelines.
Médecins Sans Frontières (MSF), the first and biggest provider of
antiretroviral therapy in Burma, says about 200,000 people are
HIV-positive in the country, and that at the end of last year, only
about 40 percent of those who required ART were receiving it.
The new WHO guidelines recommend that many more patients immediately begin the therapy.
“I don’t think the country will be able to deal with that at the
moment,” Peter Paul de Groote, MSF’s head of mission in Burma, told The
Irrawaddy on Tuesday. Despite some increase in health funding under the
quasi-civilian government that took power in 2011, he said Burma’s
health system still lagged far behind those of neighboring countries.
“We fully support the new WHO guidelines, it’s a very good development
worldwide, but you need the financial and human resources,” he said.
Tough Count
According to the new WHO guidelines, patients should begin ART when
their count of CD4 cells—the white blood cells first attacked by the
virus—falls to 500 cells per cubic millimeter of blood or below. The CD4
count indicates the extent to which a person’s immune system has been
destroyed, leaving them vulnerable to infections. The previous
guidelines, set in 2010, called for treatment at a count of 350 or
below.
Some HIV-positive patients—including pregnant women, children under
age 5, and anyone who also has active tuberculosis or hepatitis B—should
begin treatment immediately after diagnosis, irrespective of CD4
levels, according to the new recommendations.
Many scientists suggest that all patients should begin treatment
immediately upon diagnosis, to reduce the odds of spreading the disease.
But WHO’s more limited guidelines are often used by poor countries such
as Burma that depend on donor funding for medical treatment.
Ninety percent of all countries have adopted the 2010 recommendation, according to the WHO.
Burma’s current national protocol for HIV treatment follows the
previous WHO guidelines, calling for treatment when CD4 levels hit 350,
but in practice, patients are often denied care until their levels fall
much lower, to 150.
That is the case at some MSF clinics, including in Rangoon, where De
Groote said it was necessary to make tough decisions about whom to
treat.
“There are so many patients—we were forced to make a decision to take
the sickest people,” he said. “So we take 150 or below—those people are
close to dying, to be honest—and ask people with CD4 counts between 150
and 350 to come back in several months to be retested.”
Of the treatment cutoff, he added: “It was a matter of saving
lives—those patients were the sickest—just due to capacity in the
country.”
MSF, a France-based international aid organization, operates more
than 20 clinics in Burma and treats more than 30,000 HIV-positive
patients annually. It provides more than half the HIV drugs in the
country.
De Groote said it would ultimately be less expensive to start
treatment sooner—when patients’ immune systems are still relatively
strong—because doctors would not need to provide extra medicine to fight
opportunistic infections.
“If people present when asymptomatic, it’s much easier to manage them
and you don’t need all kinds of expensive treatments first to stabilize
them,” he said. “Although more people would be on treatment, in the
end, treatment per patient is relatively cheaper.”
Every provider has its own price for ART, but as a rough estimate he
said it cost about US$350 annually to treat one HIV-positive patient in
Burma, with funds spent not only on the drug therapy but also on medical
testing, human resources and medicines for other infections.
Other Hurdles
A stigma against HIV infection also hampers efforts to provide treatment in Burma.
“Discrimination, in particular against populations at higher risk of
HIV [infection], such as men who have sex with men, sex workers and
people who use drugs, is fueled by laws that criminalize such
populations, and keep people away from health facilities to access
treatment,” said Myo Thant Aung, who leads the Myanmar Positive Group,
an advocacy organization that helps HIV-positive patients in the
country. He called for more funding from the government and
international donors to work toward the new WHO guidelines, as well as a
drastic increase in HIV testing and support services.
Burmese democracy icon Aung San Suu Kyi was last year tasked with
fighting discrimination against HIV patients when she was appointed an
ambassador to the UN’s program on HIV/AIDS, UNAIDS. The Nobel laureate
and parliamentarian in May joined a candlelight vigil in honor of people
who have died from the disease, and her National League for Democracy
(NLD) party has established a few HIV treatment clinics in Rangoon.
International treatment guidelines are only one part of the puzzle,
agreed Dr. Vit Suwanvanichkij, a public health researcher who has worked
with Burmese patients on the Thai-Burma border for more than a decade.
“There are other very real structural issues too that have to be tackled
if we are to realize the goal of starting everyone on anti-retroviral
therapy, particularly earlier in the course of the disease,” he told The
Irrawaddy.
In addition to stigma against the disease and punitive laws, he cited
poor health infrastructure in the country’s rural areas as a cause for
concern.
“There must be durable peace and development in many key areas and
populations heavily affected by HIV, such as in parts of Kachin State,”
he added.
Far from Rangoon, where most of the country’s health facilities are
located, HIV is a major problem in mining areas of east Burma’s Shan
State and north Burma’s Kachin State, due to a large number of migrant
workers, high drug use and the prevalence of sex trafficking. These
states are also plagued by fighting between armed ethnic rebels and
government soldiers, who continue to clash despite peace talks.
Suwanvanichkij agreed that the new WHO recommendations would likely
have little practical effect in the country. “On the ground, providers
in Burma are already having a tough time trying to start patients on
therapy based on older guidelines, where treatment is initiated much
later in the course of the disease,” he said, adding that he did not
directly work on HIV in Burma, although he has frequently visited health
care workers in the country. “These new recommendations have the real
effect of increasing the size of the waiting list of patients needing to
start treatment urgently.”
He joined other public health researchers in calling for greater
funding from Burma’s government, which has allocated about 3 percent of
its total national budget to health care. This is an increase from past
years, when the former military junta spent less than $1 annually per
person on health care.
Much of Burma’s funding for ART comes from outside donors, especially
the Global Fund to Fight AIDS, Tuberculosis and Malaria. The
international financing organization, which suspended grants to Burma in
2005—citing political interference in its programs under the former
junta—has pledged under the new government to provide more than $160
million for the country’s HIV response through 2016.
The Fund could not immediately comment on whether the new WHO guidelines would affect its future funding allocation for Burma.
De Groote said that with the $160 million grant, it would be possible
to treat about 80 percent of patients requiring ART in Burma, based on
the previous WHO guidelines. Before talking to donors about funding to
comply with the new guidelines, he said Burma would need to show that it
had the capacity to rapidly scale up the number of people receiving
treatment.
“Every person in need of treatment should be on treatment,” he said.
“There’s a lot of work to be done, and if you look at surrounding
countries, Myanmar is behind, but catching up.”
(Source: Irrawaddy Magazine)
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