"Cho Cho" has been working in the sex industry for fewer than three years but has already been infected and has a low CD4 count. The [him] moderator finds this to be an unusual story. Even if she was infected on her first day working, she would not yet be immunocompromised.
[him] moderator
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Action: More resources for Mae Tao Clinic to provide ART to most vulnerable PLHIV in Thailand
Nyan Seik Rarmarn and Wisa S.
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“Burma Spotlight” – Reporting from the Thai National AIDS Seminar, Bangkok, Thailand, 29-31 March 2011
A Clinic in Crisis: More resources needed to provide ART to most vulnerable PLHIV in Thailand
There is no sign to indicate that this is Mae Tao Clinic (MTC), though if you watch carefully, the activity around the entrance will quickly establish this as a place with an almost constant stream of visitors. Most of these are patients of the clinic, mainly members of the surrounding communities of migrants and displaced people. They tend to be villagers who have left Burma due to the continued instability, human rights abuses perpetrated by the SPDC soldiers and the resulting lack of even the most basic health care services.
One of them, Cho Cho*, admitted she would “…already be dead if I did not receive support from MTC, especially anti-retroviral medicine treatment (ART).” Cho Cho is one of about 400 people living with HIV who are supported via the clinic’s VCCT/HIV Department.
MTC has been providing HIV-related services for more than ten years, and this department was set up in 2003. Voluntary confidential counseling and testing (VCCT), prevention of mother-to-child-transmission (PMTCT) and home-based care (HBC) make up the main sections. Services include HIV education, counseling, treatment for opportunistic infections (OI), training, nursing care for patients admitted to hospital, social support (such as referrals), monthly nutrition supplement (both rations and formula milk for infants), transportation and home visitations by peer counselors.
The latter mainly check on patients’ drug adherence, remind them of follow up dates, provide psychosocial counseling, health education and nursing care. This direct contact through peer educators is crucial, as it allows the patients, who tend to live dispersed throughout different neighborhoods, to feel less isolated. This way, they know they are part of a community. It is the same for Cho Cho, who shares her experience working at a sewing factory.
“I have to work eight hours a day and they pay me 100 Baht, not including food and additional supplies. It is hard for me to survive with this small wage but it is even harder to find a different job…I am so worried that the factory owner might find out I have HIV. If she knew, maybe she would fire me and I would become a jobless person and could no longer support my family in Burma.”
Only 25, Cho Cho grew up in Phar Pone Township, Irrawaddy Division in Burma. Her village was swept away by Cyclone Nargis in 2008, and she lost her brother and father. Although they received some help from local and international NGOs, it was not enough to support the family in the long term, so Cho Cho eventually contacted a broker to find work in Thailand. Sadly, she was unable to pay off her traveling expenses to Thailand, and the broker sold her to a brothel where her freedom of movement and communication to the outside world was quickly restricted. Though initially unaware of her new job expectations, Cho Cho soon realized what she was required to do. She knew she had to comply in order to survive, but she felt ashamed and abused.
Cho Cho’s story is unfortunately not unique, and Mae Tao Clinic will take in patients with wide-ranging backgrounds and experiences. The clinic does not discriminate against anyone who seeks care, and so the numbers of people living with HIV is growing steadily. Currently, 32 individuals are on first-line ART. Added to this group are a further 46, who had initially received medication through an international organization that closed operations in the area.
Most of these are lucky to be part of the extension program of the Thai National Access to antiretroviral Program for People living with HIV/AIDS, or NAPHA Extension Program. MTC is not authorised to distribute ARVs, so the drugs are delivered from nearby Thai hospitals that participate in the NAPHA extension program, which was established expressly for people outside the formal health care system, often those without legal documentation.
“The problem,” as the MTC HIV Program Manager explained, “ is that NAPHA extension follows a quota system and cannot cover all patients in need of ART. In 2010, there were only two new NAPHA extension spots available at Mae Sot Hospital, of which only one has been filled while waiting for more testing for the second spot. Currently, at least 20 new patients are waiting for ARVs in MTC’s inpatient department (IPD), and the only thing the staff can really do is to try and ease their discomfort and make their time as bearable as possible. Many are displaying tell-tale symptoms like recurring skin infections, and one patient has CD4 count less than 200.”
These conditions point to a serious gap in Thailand’s service provision system for people living with HIV.
At last week’s National AIDS Seminar in Bangkok, Ms Supatra Nacapew, Director of the Foundation for AIDS Rights, said that it was one of the long-term civil society goals to provide 100% free ARV coverage to every PLHIV in need – regardless of official status in the country. In other words, undocumented migrants, refugees and displaced people had as much right to ART as Thai citizens. This formed part of the human rights-based approach to coordinating the HIV-related health care package in Thailand.
Ironically, VCCT services tend to be more than ready and available to test people across the country. This leads to depressing situations where members of mobile populations have positive test results and require ART, which cannot be provided to the existing gap in supplies.
The Mae Tao Clinic HIV Program Manager shared that “…in 2010 alone, MTC’s laboratory performed 5,158 HIV screening tests, with 284 subsequently confirmed positive by ELISA testing at Mae Sot Hospital. Blood donor testing at Mae Sot Hospital added a further 2,218 tests of which 18 were positive. Thus the combined total for 2010 was 7,376 HIV tests performed on MTC clients, with over 300 positive results.”
Cho Cho was one of those who chose to get tested some years ago. She had been lucky to escape from the brothel holding her with the support of a local community-based organization.
“Anytime I thought about my previous job, I felt so sad and unsafe. So I decided to get tested for HIV and it came back that I was HIV positive. Of course I was very upset, but I consulted with an HIV counselor MTC, who helped me access more information about taking care of myself.”
Cho Cho now receives regular support from MTC and she will sometimes use her free time on the weekends to help out at MTC. She also has access to self care group discussions, which 60 to 80 patients join with their families and staff, meeting at monasteries, public parks, migrant schools, or other sites.
Others have been less lucky. In the first few months of 2011, twelve MTC patients died because of a lack of access to ART. The clinic does not have the budget to buy ARVs from another provider, and is therefore forced to support new patients in urgent need through palliative care, a poor substitute for life-saving medication.
Despite these and many other obstacles – including continued stigma and discrimination, harassment by Thai police, and people’s fear of deportation – Mae Tao Clinic will continue to try and find the most appropriate solutions, together with the many other local organizations working to improve health conditions for these individuals and families living with and affected by HIV, and AIDS.**
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*This is not her real name, and Cho Cho’s story is a composite of several female patients at MTC.
** Mae Tao Clinic collaborates with Mae Sod Hospital, World Vision Foundation of Thailand, Social Action for Women (SAW), Foundation for the Health and Knowledge of Ethnic Labour (MAP), and the Social and Health Development Association (SHDA) in providing medical and social support to PLHIV.
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