Here are comments from a reader with the [him] moderator's replies intercalated. It may be easier for you to read with the extra formatting on the website. Thanks to the reader for taking the time to add to the discussion. It is remarkable that this reader and the [him] moderator agree on many points. Though from very different perspectives.

[him] moderator

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Reader: I would like to put some comments with four issues that were raised at HIM recently;

1.       “There is no shortfall in HIV and AIDS drugs in Myanmar”

original quote from HIM: “For the second time in a couple of months we are treated to an MSF story that oversimplifies the challenges of increasing the number of people living with HIV taking antiretroviral therapy. This time the story was even more widely spread in the mass media. And the facts are even more distorted than they were before. In fact, there is no shortfall in HIV and AIDS drugs (Are they different?) in Myanmar. There are presently enough drugs in the country for the people taking them and stockouts are rare."

Reader: I have no idea where this information comes from. Yes, there are enough drugs for most people who are taking them. But there are not enough drugs for people who are not taking them.

I asked 10 organizations who are implementing ART activities what they would do if they had access to more funds. They ALL said that they would treat more patients. First of all the thousands of patients who are on their waiting lists.

Some organizations said that they already decreased the enrolment of new patients on ART over the past months. Others said that they are going to decrease the enrolment of new patients in the near future and one organization is planning to hand over their patients and stop ART altogether. MSF treats only a portion of the patients presenting at their clinics and have therefore many patients on their waiting lists.  All organizations mentioned a lack of funding as the cause for these limitations in enrolment of new patients on ART.

Clearly, these organizations currently have the capacity to enrol thousands of new patients. But they are scaling down new enrolments because of lack of funds. And the DoH probably also have capacity to increase enrolment.

Additional money would be the immediate and life saving solution for many thousands of patients. Suggesting the opposite is wrong.

[him] moderator replies - You write: "Yes, there are enough drugs for most people who are taking them." We agree that there is no shortfall of drugs in the country.

2.       “Access … in other places in-country”

original quote from HIM: "The HIM moderator has received the following comment on his post yesterday about the MSF story: I think we need to figure out issue of access and data in a lot of other places in-country before we keep ringing the funding bell.  Shouldn't we be including that in the equation and ringing that bell? Then there is the fundamental question of human resource abilities to deliver. It just isnt a matter of simple scale up at this point. Yes, lack of funding is ONE of many constraints, but throwing money at the problem might not be the solution we need."

Reader: "I assume that the author meant that access to ART is restricted in other places in country. If so, I would agree that access in some areas is much easier than in other areas. Having said that, it is physically possible for most in this country to reach a clinic with ART services. In my own experience patients come sometimes from far, some travel over 100 miles by bus. Even from the so-called black zones. For follow-up visits we provide these patients with money to pay for the bus fees to compensate for their expenses (and facilitate good compliance). Interestingly, in the long run the outcome indicators (deaths or lost to follow up) of patients who live far away from the clinic were the same as patients who lived nearby.

Sure, an issue is that many people are not aware of the existence of the ART services. And we could provide better information to people who live in remote areas to increase the awareness to get access to ART. But the problem here is that we are worried that a large scale awareness campaign will cause a large scale rush to clinics which provide ART while we already not have enough medicines for the people that are coming to the clinics now.  We would not be able to absorb an extra influx of patients and thus the people who we would reach with the awareness campaign would make a long travel only to be extremely disappointed. Years ago such an information campaign was launched and MSF clinics were swamped with people who needed ART. But MSF had a limited budget for ART and could not treat many thousands of them and the situation was extremely disappointing for these patients. Personally I would advocate for such an information campaign, but we first need to have access to a large amount of extra medicines, so that we can offer the services mentioned in the information campaign. And of course we also need more clinics that can provide ART in remote areas."

[him] moderator replies: You write: "And of course we also need more clinics that can provide ART in remote areas." The comment that you are responding to is from a reader and was not written by the [him] moderator. But we three all agree that one of the constraints is lack of clinics in areas remote from the heartland.

3.       Another issue raised at HIM was the apparent uselessness of MSF and UN inspired mass media activities to ask for more money.

original quote from HIM: Maybe Im missing something here. Will someone explain it to me? Last month MSF said more funding is needed. Now the UN repeats that more funding is needed. This is not news and there is hardly a story at all. Blanketing the mass media with repeated information that more money (or medications) is needed may not be the most strategic way to get more funding. If these stories are to have an impact, where does MSF or the UN think that the funding will come from? Certainly not from the UN as the UN is broke. Certainly not from the Global Fund as they will not fund until Round 11A or Round 12 late next year. The Global Fund Round 9 grant renewal this summer may be subject to a budget reduction of 25%. From other bilaterals? The Three Diseases Fund could get a bit more money, but then who would apportion prevention and treatment funds? New bilaterals? Does anyone really want a lot of USAID money? It could come, but is likely to roll out later than Global Fund resources. Who are all these MSF and UN inspired pieces directed to?

Reader: HIM seems to think that HIV treatment can & is only/mainly funded by large donors like GF and 3DF. Of course they are significant and that's why we keep putting pressure on them for more money. But many NGOs get their funding largely from private funding, individuals (including Myanmar citizens) and private foundations. MSF, the largest provider of ART in Myanmar, and several smaller NGOs have financed most of their ART activities from their own private fund raising activities.

In addition one could argue that a general awareness about the plight of people with AIDS in Myanmar would make funding for more AIDS activities in Myanmar, which is still comparatively very low, more acceptable."

[him] moderator replies: You write: "But many NGOs get their funding largely from private funding, individuals (including Myanmar citizens) and private foundations." I would like more information on this. Which "many NGOs" other than MSF and Medical Action Myanmar get their funding LARGELY from these other sources? And my original question is still unanswered: "Who are all these MSF and UN inspired pieces directed to?" Are the other sources a secret? Is a mass media campaign the best way to achieve the goals of advocacy?

4.       The issue of starting ART or discontinuing and the effect on prevalence;

original quote from HIM: Craig may be Canadian but he is wrong when he says that discontinuing treatment would lead to an increase in prevalence. It would lead to a rapid decrease in prevalence as people die. Treatment INCREASES prevalence as more people with HIV live longer. Phyu Phyu correctly points out that one of the major causes of the decline in national prevalence is death. Prevention efforts also play a role.

Reader: "All true. And there are more sides on the effect of stopping ART. Initially the patients will get a higher viral load and will therefore become more infectious. This has an increasing effect on HIV prevalence. Secondly, the patients will die. And this has a decreasing effect on HIV prevalence.

Treatment increases prevalence as more people with HIV live longer. But also, as a result of ART, infectiousness of patients is rapidly going down. This can, in the long run, have a decreasing effect on prevalence. I hereby attach some interesting articles about this topic. There is increasing evidence that Treatment as Prevention can have a major impact on preventing new HIV infections (Science called "Treatment as Prevention" the breakthrough of the year). An extra good reason to ask for more funding for AIDS treatment."

[him] moderator replies: You write: "All true." We agree on this. Treatment is a human right. "Treatment as prevention" may get media acccolades but has not been proven effective at population level outside of discordant couples and has not been proven effective at population level among people who inject drugs.