Money is not the only constraint to increasing coverage of antiretroviral treatment. "Mr de Groote said there were other challenges to expanding coverage. Improvements would need to made to treatment models and care would need to be decentralised."

Right.

Jamie

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Hurdles to meeting new WHO guidelines on HIV
Shwe Yee Saw Myint
Myanmar Times
Monday, 22 July 2013

Myanmar will have difficulty meeting the World Health Organization’s call for more aggressive and widespread provision of treatment for HIV sufferers because of financial and capacity constraints, the Ministry of Health says.

The WHO’s new HIV treatment guidelines, released June 30, call for antiretroviral therapy (ART) for all children with HIV under five years of age, as well as all pregnant and breastfeeding women with HIV.

It also calls on all countries to offer anti-retroviral treatment (ART) to anyone with a white blood cell count below 500 CD4 cells/mm3, something a spokesperson for the ministry’s HIV department said will pose challenges here due to a shortage of available drugs.

However, Myanmar is unable to meet the earlier WHO guideline, which recommends the provision of ART to those with a CD4 count below 350.

“To implement the new guideline, the government and UN organisations need to [improve] access to ART drugs,” said Dr Tun Nyant Oo. “[But] Myanmar cannot easily change [its policy] to follow this guideline.”

The CD4 count is considered an indication of the state of a patient’s immune system, with a lower number representing a weaker immune system. In keeping with the 2012 National Protocol, which adopted the previous WHO recommendation set in 2010, Myanmar is offering ART treatment to all patients with CD4 counts below 350.

Even so, Dr Tun Nyant Oo said, many patients in need of care are still missing out. Of the 125,000 people with a CD4 count of 350 and below, “over 70,000 patients are not receiving the required treatment”, he said.

Ministry data from 2013 shows that 50,000 HIV patients are receiving ART treatment in Myanmar, including 4000 children and 700 pregnant women.

Peter Paul de Groote, head of Médicins Sans Frontières Holland in Myanmar, agreed many were missing out under the current guidelines.

MSF has been working in Myanmar since 1992 and started providing ART treatment in 2003. It has more than 30,000 patients on ART medication at clinics in Kachin State, northern Shan State, Tanintharyi Region, Yangon Region and Rakhine State.

“In most locations we are enrolling patients with a CD4 of 350 and below,” Mr de Groote said. “In certain locations, however, we have been using lower criteria due to the overwhelming needs.”

Lack of funding for ART provision is one challenge. Last month the Global Fund to Fight Aids, Tuberculosis and Malaria approved a US$161 million grant to combat HIV/AIDS in Myanmar until the end of 2016. The amount is estimated to be enough to provide ART to 106,000 people, an estimated 85pc of those in need.

But Mr de Groote said there were other challenges to expanding coverage. Improvements would need to made to treatment models and care would need to be decentralised. Increasing the number of patients who qualify for ART will also require a change in the national protocol.

For patients from more remote regions, ART is often unattainable because they cannot afford to travel to places where it is offered.

One patient from a village in Ayeyarwady Region’s Labutta township, who is staying at Daw Phyu Phyu Thin’s clinic in Yangon, said she was only able to seek treatment after her community paid for her travel expenses.

“I only found out I had HIV last month when I went to the township hospital because I had diarrhoea. The doctors then referred me to Yangon because they said I needed ART but it was very difficult for me to get to Yangon,” she said, adding that her CD4 count is below 200.

“Finally, I arrived here thanks to the support of some people in my township and I’ve been receiving treatment for about two weeks from [MSF Holland].”

Daw Phyu Phyu Thin, who is also a Pyithu Hluttaw representative for Mingalar Taung Nyunt, said most patients arrive at her clinic with CD4 counts below 200. “I try to send them to [MSF] clinics to get ART as soon as possible, and get them sent to hospital,” she said.

“To get ART treatment they have to spend at least three months in Yangon … Some patients never come back to Yangon to get ART for a second time because they don’t have the money.”

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