For decades, Myanmar’s struggle against HIV/AIDS was held back by the former junta’s reluctance to acknowledge the scale of the crisis facing the country. As a leading expert on the disease since the 1990s, Dr. Chris Beyrer of the Johns Hopkins Bloomberg School of Public Health, in the US city of Baltimore, has long been at the forefront of efforts raise the alarm in Myanmar, which he warned in 2005 faced an explosion of HIV comparable to that of the worst-hit parts of Africa.
Dr. Beyrer recently spoke with The Irrawaddy’s Marwaan Macan-Markar about the current state of Myanmar’s HIV crisis in the wake of recent political reforms. Although many things have improved, he says, the country still has vast unmet health-care needs, with 220,000 people living with HIV and only around half of the estimated 120,000 patients requiring anti-retroviral (ARV) therapy receiving it—and most of those in Yangon and Mandalay, the two largest cities.
Still, says Dr. Beyrer, the country’s newfound openness could have a dramatic impact on how well it can contain the spread of the deadly disease. But, he adds, much remains to be learned about how deeply rural regions have been affected by decades of neglect.
Question: It is now nearly three years since President U Thein Sein paved the way for political liberalization in Myanmar. Has this opening made a difference to the tens of thousands of people living with HIV and those vulnerable to being infected in the country?
Answer: There is much more freedom of information now. And I think the single biggest change has been the end of censorship and the opening the media for greater and more open discussions. That, of course, has very great implications for HIV and the people with HIV. It has also marked the end of isolation for HIV professionals, and there has been a large increase in international donor engagement. And what we understand is there will be 50,000 new treatment slots in the pipeline [for people with HIV to gain access to ARVs].
Q: How are the country’s public health professionals coping with this shift?
A: What the people in the Health Ministry and in the national AIDS program say is that, earlier, they were waiting for resources to come, but now that they are coming, there is a big challenge to strengthen the absorptive capacity. They have to be able to handle that volume of increased funding and increased treatment. This is going to be a real challenge.
The backbone of the public health system in Myanmar is midwives and nurses, particularly in rural areas. There will have to be a lot of what is called “task shifting,” with many more healthcare workers being able to support people with HIV.
Q: What shift in policies is required to make the access to 50,000 new treatment slots for people with HIV meaningful?
A: Until now, the government’s treatment program had been accessible to people with HIV when it is very late. The levels of the CD4 [the white blood cell that targets the virus] count calculations had been so low that people have full-blown AIDS before they are started on therapy. And that is not good. It is much better to start earlier, when their immune system could recover and they can benefit from the treatment. And that is what MSF [humanitarian aid organization Médecins Sans Frontières]was trying to do during all these years, since it has been a major treatment player. About half the people being treated were treated through MSF.
Q: But even this expansion of treatment and care seems to be concentrated in urban areas, as before. How worrying is it that HIV-related care is still limited in large stretches of the country, in ethnic areas shattered by conflicts?
A: [The problem is] not just in the conflict zones, but also in the less medically served rural areas, where we still do not have a good handle on what the HIV prevalence rate is. For example, if you look at India, the states with the highest HIV rates are Nagaland and Manipur [on the Myanmar-India border]. And if you look at the [Myanmar] side of Nagaland, there is no HIV care program. And we know that if it is high on the Indian side, it is certainly as high on the [Myanmar] side. There is no treatment capacity there, no laboratory capacity, so you know there are whole parts of the country that have not been reached for HIV testing.
So I think one of the things we hope for in this new period of openness and transparency, and as the medical information and health system improves, is that we will start to get a better assessment of HIV prevalence rates. I don’t think anybody knows what the exact figure is. But what they are reporting now is a low prevalence rate.
Q: The HIV prevalence rates were a very politically sensitive issue when the country was under the junta. What was it like for your contacts in the Health Ministry during military rule?
A: It was terrible for them. They were isolated. They knew the country had a very severe epidemic, but people in the ministry were under pressure. A very senior official in the ministry told me he was once ordered by a general to lower the HIV rates, because [Myanmar] had to have a lower infection rate than Cambodia.
Q: What year was that?
A: It could have been either 2003, ’04 or ’05.
Q: How about you? Your research on HIV was also not well received by the military regime.
A: Yes. We had done an assessment of the epidemic in 2000, and our estimates were vigorously attacked by the government. And then, since the political liberalization, one of the people involved in that attack came to see me in Baltimore—he came to my office out of the blue. I didn’t know who he was, but he said he was visiting the US as a scholar. And he came to apologize. He told me he was sorry and that I was right, but they had been ordered to attack me. It was nice to be right, but it didn’t help all those people with HIV in the country.
This story was first published in the February 2014 print edition of The Irrawaddy magazine.