New Global HIV Guidelines Highlight Burma’s Health Care Woes

By Samantha Michaels 2 July 2013

RANGOON — 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, an 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.”