World AIDS Day 2021: Myanmar’s political turmoil threatens HIV care
After the military seized power from Myanmar’s democratically elected government on February 1, 2021, doctors and nurses were among the first to lead the protests – walking out of their jobs days after. This had an overwhelming impact on the public healthcare system, including the National AIDS Program (NAP), which provides medication, consultations and counselling to more than 150,000 people living with HIV.
The impact on people living with HIV
Delayed diagnosis or interrupted treatment is devastating for people living with HIV. It leads to increased levels of the virus in their blood, weakening their immune system and leaving their body struggling to fight off potentially deadly opportunistic infections. And if HIV is not diagnosed until it is in an advanced stage, it becomes less responsive to treatment.
There were 2,929 missed appointments at Doctors Without Borders/Médecins Sans Frontières (MSF) clinics between February and October, an 89 percent increase on the same period last year. Worryingly, we are seeing many patients who we cannot contact at all. In Shan state our community outreach workers have lost touch with 120 people since February – a 50 percent increase year-on-year – and for these people there is little we can do.
The risk is not only for the patients themselves. Higher virus levels also increase the likelihood of transmitting HIV to others. If many people default on their treatment or cannot get their condition diagnosed and begin antiretroviral therapy, we could see widespread infections across communities that roll back years of progress made on tackling the epidemic.
The broader impacts of the recent political turmoil on Myanmar’s public healthcare system has seen many hospitals shut or offer only a limited range of services while staff are on strike. This means we have few options for referrals for our HIV patients when their needs are critical, threatening the lives of our most at-risk patients.
MSF stepping up to fill the HIV services gap
Although it has been slowly recovering over the past 10 months, the NAP is not in a position to return to accepting patients from MSF into its program. We will not be considering restarting the transfer of patients until 2023 at the earliest. Many NAP facilities still only offer very limited services, if they are functioning at all. Diagnosis and initiation of treatment for new patients has stopped in many sites. More remote facilities may only be staffed by a single nurse who can provide medication but cannot test blood to monitor viral loads or handle more complex patients whose HIV is in a later, more critical stage.
This has seen a reversal of MSF’s strategy to downscale HIV activities. We are now diagnosing and beginning treatment for new patients in large numbers for the first time since 2019 – registering 399 since the military took power – and NAP patients have visited MSF facilities in Shan, Kachin and Tanintharyi over 7,200 times to continue their care because the government clinics are unable to support them.
MSF’s capacity to respond
The extent to which our clinics can step up to meet the demands varies. In Kachin state we can provide drug refills, diagnosis and check-ups, but the volume of NAP patients coming to our facilities in Shan state is so large it limits the support we can offer.
This spike in patients, alongside interrupted drug imports, has threatened our medical supplies. For months, we could only offer shorter prescriptions of anti-retroviral drugs, and now we are running low on medications to treat opportunistic infections among people living with HIV, such as fungal meningitis, and equipment needed to diagnose HIV in early infants. If these stocks dry up, it could cause fatal outcomes for patients.
Challenging journeys to MSF’s HIV clinics
Myanmar’s political instability has ignited conflict between the Myanmar military on one side, and pro-democracy civilian militias and ethnic armed organizations on the other. Assassinations, targeted bombings and battles over territory are commonplace across the country.
Many people visiting our clinics must travel a long way, and these journeys are now fraught with challenges that may deter them from making the trip. Intimidating military and police checkpoints, where people are searched and must pay “tea money” to pass through, are widespread. A 10pm-4am curfew gives people less time to reach the clinic and get home in time, while sporadic acts of violence pose a risk to people travelling some routes.
“The road between Chipwe and Myitkyina has been officially closed for months, so there are many checkpoints and few drivers dare to come,” says Brang Seng*, 30, who was only diagnosed with HIV in April and has to make frequent visits to the MSF clinic as he begins treatment.
“I am worried about conflict escalating, which would stop me from being able to travel, and then missing my appointment, so I came earlier. I can only come when there is a taxi. They are not every day.”
Myanmar’s devastated economy limits access to healthcare
The COVID-19 pandemic, coupled with the Myanmar military seizing power, has left the country’s economy in tatters. Many people are out of work and soaring inflation has pushed up the costs of everyday staples, particularly food and petrol.
Affordable inter-city trains are not running and bus routes are not reliable either, meaning people have to use more expensive private cars or motorbikes. For our HIV patients, this means additional costs reaching our clinics while their purse strings are tighter.
Although he could make it to the MSF clinic in Moegaung, Kachin state, HIV patient U Hla Tun’s* experiences illustrate the challenges people in Myanmar have been facing since February. He makes a living transporting piglets on his motorbike from where he lives in Karmine to sell them in the jade-mining town of Hpakant. Previously, each trip would earn him as much as 100,000 kyats (US$55). But with Hpakant facing an internet blackout and insecurity due to fighting, demand for livestock is down and he is unable to move as easily as he did before.
“It became too difficult to travel. I cannot go around the area and sell due to the fighting and COVID. There are few buyers left and my business is almost paused,” he says. “There is no guarantee of security in Hpakant, so people don’t want to buy and raise pigs anymore.”
All obstacles to providing HIV care need to be dismantled.
For those patients who cannot reach our clinics due to barriers like these, we can still provide them with medication via public transport – in Shan state we have made 270 deliveries since February. But this is not a long-term solution. Patients whose conditions are unstable need to see medical doctors, and without those consultations and tests they receive at our clinics, they are not getting sufficient quality of care.
It is vital that people living with HIV in Myanmar have reliable access to healthcare. This means a fully functioning National AIDS Program, and in lieu of that a community of actors who can fill the gaps. With donors unable to direct funds through Myanmar’s military government, which would be considered tacit support, it may be that organizations like MSF have to continue to step in until there is a shift in the political landscape. Continued funding for HIV services in Myanmar is, therefore, vital.
All obstacles to providing HIV care need to be dismantled. Ensuring import permits are always available for drugs and other medical supplies is a quick win, but the conflict and economic strife that impact our patients’ access to healthcare in Myanmar will take much more time and work to address.
Names have been changes to preserve anonymity.