The report "A preventable fate: The failure of ART scale-up in Myanmar" makes some valuable points.

Official development assistance is low compared to regional aid darlings like Cambodia and Vietnam, access to lifesaving antiretroviral therapy is a human right, and scaling up is difficult.

But the report begs the question of why MSF cannot increase the number of people it treats. It would be more helpful to all if was clear about why MSF has painfully decided not to increase the number of people and listed the resources that MSF is lacking to scale up: human, material, organisational, financial, etc.

There is not a word from MSF about prevention. Better coverage of prevention services would obviate the need for treatment over the next decade.

The full report is available on the [him] blogsite and the executive summary is below.

[him] moderator

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Executive Summary

The situation for many people living with HIV in Myanmar is critical due to a severe lack of lifesaving antiretroviral treatment (ART). MSF currently provides ART to more than 11,000 people. That is the majority of all available treatment countrywide but only a small fraction of what is urgently needed. For five years MSF has continually developed its HIV/AIDS programme to respond to the extensive needs, whilst the response of both the Government of Myanmar and the international community has remained minimal. MSF should not bear the main responsibility for one of Asia's most serious HIV/AIDS epidemics. Pushed to its limit by the lack of other services providing ART, MSF has had to make the painful decision to restrict the number of new patients it can treat.  With few options to refer new patients for treatment elsewhere, the situation is dire.

An estimated 240,000  people are currently infected with HIV in Myanmar. 76,000 of these people are in urgent need of ART, yet less than 20%  of them receive it through the combined efforts of MSF, other international non-governmental organizations (NGOs) and the Government of Myanmar. For the remaining people the private market offers little assistance as the most commonly used first-line treatment costs the equivalent of a month's average wage. The lack of accessible treatment resulted in 25,000  AIDS related deaths in 2007 and a similar number of people are expected to suffer the same fate this year, unless HIV/AIDS services - most importantly the provision of ART - are urgently scaled-up.

The Government of Myanmar and the International Community need to mobilize quickly in order to address this situation. Currently, the Government spends a mere 0.3% of the gross domestic product on health, the lowest amount worldwide , a small portion of which goes to HIV/AIDS. Likewise, overseas development aid for Myanmar is the second lowest per capita worldwide  and few of the big international donors provide any resources to the country. Yet, 189 member states of the United Nations, including Myanmar, endorsed the Millennium Development Goals, including the aim to "Achieve universal access to treatment for HIV/AIDS for all those who need it, by 2010". As it stands, this remains a far cry from becoming a reality in Myanmar.

As an MSF ART patient in Myanmar stated, "All people must have a spirit of humanity in helping HIV patients regardless of nation, organization or government.  We are all human beings so we must help each other". MSF insists that the Government of Myanmar and international organizations urgently and rapidly scale-up ART provision. A vast gulf exists between the needs related to HIV/AIDS and the services provided. Unless ART provision is rapidly scaled-up many more people will needlessly suffer and die.

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Thousands dying for lack of treatment

JOHANNESBURG, 26 November 2008 (PlusNews) - Thousands of people living with HIV in Myanmar (Burma) are dying because the government and international donors are not funding life-prolonging antiretroviral (ARV) drugs, says international humanitarian organisation, Médecins Sans Frontières (MSF).

In a report released today, MSF said it could not continue shouldering the main burden of responding to Myanmar's HIV crisis, in which around 240,000 people are infected.

Of the 76,000 people in Myanmar estimated to be in need of ARVs, only about 20 percent are getting the drugs, the majority of them (about 11,000) through MSF.

According to both the MSF report and UNAIDS, the government has allocated only US$200,000 to HIV/AIDS in 2008 and is providing ARVs to around 2,000 patients. MSF is still awaiting permission to start providing ARVs in parts of the country where treatment is only available in the private sector.

Most of Myanmar's population live on an average of the equivalent of US$1.20 per day, putting the cost of buying ARVs in the private sector far beyond their means. MSF notes in its report that in 2007 around 25,000 people died of AIDS-related illnesses.

"A similar number of people could suffer the same fate in 2008 unless there is a significant increase in accessible ART [antiretroviral treatment]," said MSF operations manager Joe Belliveau.

According the United Nations Development Programme, the government spends just 0.3 percent of its gross domestic product on health - the lowest in the world - and the country is also the second lowest per capita recipient of international development aid.

MSF's Country Director in Myanmar, Frank Smithuis, pointed out that most developing countries received significant donor support for their national HIV programmes, but few of the major AIDS donors have given money to Myanmar.

"I don't want to take away the responsibility of the government, but if you look at Laos, they only spent US$30,000 [of government money] on ART, but they have 95 percent coverage because they get a lot of international donor money," Smithuis told IRIN/PlusNews. "You can talk about politics for days but in the meantime there are people dying."

Sun Gang, UNAIDS country director for Myanmar, acknowledged donor concerns about the government's lack of transparency and accountability, but said there had been improvements on these fronts in the past year.

''You can talk about politics for days but in the meantime there are people dying''

Gang confirmed that although a number of non-governmental organisations (NGOs) in Myanmar are doing HIV prevention work and providing care to people living with HIV, MSF is among only a handful providing treatment.

"We are reaching our limit," said Smithuis. "We cannot put all the resources we have in the world into Myanmar alone, so we'd really like other organisations to help shoulder the burden and, of course, the Department of Health."

The report says MSF has been forced to make the decision to limit the number of new patients it accepts for treatment, and urges other international NGOs to step in.

"We are supportive of the call to expand international support," said Gang, "but not only for treatment, but also for prevention."

Gang pointed out that men who have sex with men are among the most high risk groups for HIV infection in Myanmar but that only around 10 percent were being reached with prevention interventions.

"In this country, although we see a burning need to get more people on treatment, there's also a burning need to do more prevention."

http://www.plusnews.org/Report.aspx?ReportId=81673

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Press release
A preventable fate: The failure of ART scale-up in Myanmar
November 26, Medecins Sans Frontieres

The situation for many people living with HIV in Myanmar is critical due
to a severe lack of lifesaving antiretroviral treatment (ART). MSF
currently provides ART to more than 11,000 people. That is the majority of
all available treatment countrywide but only a small fraction of what is
urgently needed. For five years MSF has continually developed its HIV/AIDS
programme to respond to the extensive needs, whilst the response of both
the Government of Myanmar and the international community has remained
minimal.

MSF should not bear the main responsibility for one of Asia?s most serious
HIV/AIDS epidemics. Pushed to its limit by the lack of other services
providing ART, MSF has had to make the painful decision to restrict the
number of new patients it can treat. With few options to refer new
patients for treatment elsewhere, the situation is dire.

An estimated 240,000 people are currently infected with HIV in Myanmar.
76,000 of these people are in urgent need of ART, yet less than 20 % of
them receive it through the combined efforts of MSF, other international
non-governmental organizations (NGOs) and the Government of Myanmar.

For the remaining people the private market offers little assistance as
the most commonly used first-line treatment costs the equivalent of a
month?s average wage. The lack of accessible treatment resulted in 25,000
AIDS related deaths in 2007 and a similar number of people are expected to
suffer the same fate this year, unless HIV/AIDS services - most
importantly the provision of ART - are urgently scaled-up.

The Government of Myanmar and the International Community need to mobilize
quickly in order to address this situation. Currently, the Government
spends a mere 0.3% of the gross domestic product on health, the lowest
amount worldwide, a small portion of which goes to HIV/AIDS. Likewise,
overseas development aid for Myanmar is the second lowest per capita
worldwide and few of the big international donors provide any resources to
the country. Yet, 189 member states of the United Nations, including
Myanmar, endorsed the Millennium Development Goals, including the aim to
?Achieve universal access to treatment for HIV/AIDS for all those who need
it, by 2010?. As it stands, this remains a far cry from becoming a reality
in Myanmar.

As an MSF ART patient in Myanmar stated, ?All people must have a spirit of
humanity in helping HIV patients regardless of nation, organization or
government. We are all human beings so we must help each other?. Unable to
continue shouldering the primary responsibility for responding to one of
Asia?s worst HIV crises, MSF insists that the Government of Myanmar and
international organizations urgently and rapidly scale-up ART provision. A
vast gulf exists between the needs related to HIV/AIDS and the services
provided. Unless ART provision is rapidly scaled-up many more people will
needlessly suffer and die.

Myanmar is experiencing one of Asia?s most serious HIV epidemics, yet the
available care and treatment meets only a fraction of the needs. As a
result people are dying unnecessarily, people who are desperate to live
and contribute to their family, community and country. An estimated
240,000 people are thought to have HIV in Myanmar. Of these people, 76,000
are in urgent need of lifesaving antiretroviral therapy, yet less than 20%
of those in need of treatment receive it.

This is one of the lowest coverage rates for ART coverage worldwide. As it
stands, MSF provides ART to more than 11,000 people, which makes up the
majority of all available treatment countrywide. The Government of Myanmar
and other non-governmental organizations (NGOs) provide ART to around
4,000 people. While there are a number of NGOs working in HIV/AIDS in the
country, efforts are largely focused on the provision of care rather than
treatment. Although well meant, care alone can only support people in
dying, whereas ART can assist people to live. Having put significant
resources into its Myanmar programme, MSF can no longer continue to
scale-up ART provision, in the face of so little response by other actors.
Therefore, it has had to make the painful decision to restrict the number
of new patients it can treat. With few options to refer new patients for
treatment elsewhere, the situation is dire.

For the thousands of people unable to access free ART there are very few
other options open to them. The cost per month of the most commonly used
first-line ART in a private pharmacy in Myanmar is $29. This is far beyond
the means of most people who on average live on $1.2 per day. Even if
people can find a way to afford ART many often become indebted and are
soon forced to stop. This leaves families not only with the trauma of
losing a loved one, often the main income-provider for the family, but
also with crippling debt.

Alternatively, some patients are only able to source treatment
irregularly, when finances allow or family and friends assist. This can
lead to the rapid development of drug resistance.

On the one hand, Myanmar has a weak and under-funded state healthcare
system. The Government of Myanmar spends a mere 0.3% of its gross domestic
product on health, the lowest amount worldwide. In 2007 the Government
spent just USD$ 0.7 per person on health, with the 2008 annual HIV/AIDS
budget estimated at just USD$ 200,000 in total. With growing revenue from
oil and gas exports, the Government must invest more in its ailing health
system and specifically HIV/AIDS care and treatment.

On the other hand, overseas development aid (ODA) to Myanmar is the second
lowest per capita worldwide, after India. Compared to some of Myanmar?s
neighbouring countries it receives a tiny fraction of the ODA they do. Few
of the big international donors, such as the Global Fund, World Bank,
Asian Development Fund, and the President?s Fund invest in the Government
health system out of concern over the effective use of funds. Whatever
their reasons, there is a massive under-investment in assistance in
Myanmar and it is the general population who are suffering and will
continue to suffer unless this changes.

Other international actors, including NGOs, who could fund HIV/AIDS
treatment and care in Myanmar have been hesitant. This may be due to
concerns that the substantial improvements in the Government health system
necessary to facilitate an eventual hand-over of patients will not
materialize. Alternatively, organizations may be put off by the challenges
posed by working in a country like Myanmar, including official constraints
and difficult bureaucratic procedures. In some areas of the country, such
as Kayah state, MSF has not been permitted to start AIDS treatment. These
legitimate concerns however should not dissuade organizations from
providing assistance where it is most needed. MSF has proven that
providing independent and effective humanitarian assistance to people in
Myanmar is possible and more to the point critical if unnecessary deaths
are to be prevented.

MSF has provided essential healthcare services in Myanmar since 1993 and
began a programme to support people living with HIV/AIDS in 2003. Since
then, MSF staff has assisted thousands of HIV patients, working from 23
clinics, in five areas throughout the country. Services include
counseling, testing, treatment of opportunistic infections, nutritional
support, health education and most importantly antiretroviral treatment.

At the time of publishing this report, MSF provides ART to more than
11,000 patients. Patients are selected independently, purely on medical
grounds and without political interference. Medicines are distributed
directly to the patient. Monitoring of the program is done at the level of
the beneficiary; an essential element of the program that helps to
guarantee that the population benefits directly from MSF?s services and
that donor money is spent transparently.

Having made an enormous effort to respond to the overwhelming need for ART
treatment during the last five years, MSF can no longer take primary
responsibility for ART scale-up in Myanmar. Pushed to its limit by the
lack of treatment on offer by other care providers, MSF has recently been
forced to make the painful decision to drastically reduce the number of
new patients it can treat. With few options to refer new patients for
treatment elsewhere, the situation is traumatic for both patients and
staff.

MSF calls for all sectors to urgently and rapidly scale-up lifesaving
HIV/AIDS treatment in Myanmar, in the face of overwhelming needs. The
public sector, through the Myanmar Department of Health (DoH), must take
the lead and drive the scale-up of HIV/AIDS services, most importantly
ART, with the support of international donors and organizations.

During the last two years, the DoH has treated patients with ART in 22
hospitals around the country, treating an estimated 1,800 people. This
covers just a fraction of the needs, but is a good basis on which to
develop services. DoH is the only actor with long-term potential to
provide sustainable ART nationally. At present some of the DoH ART sites
have a limit of just 20 patients. Such low numbers are not cost-effective
and make the initial investment in set-up, training and ongoing drug
supply hard to justify unless numbers are increased considerably. Once a
site is established there need to be ambitious plans set to expand care
and treatment.

DoH has shown signs of wanting to develop its services in HIV/AIDS and
must be supported to realize these ambitions. Geographical coverage also
needs to be expanded, in areas such as Chin and Kayah states, which have
no ART programmess at all. In Kayah State, some AIDS patients are
attempting to access treatment in neighboring Thailand, which makes them
vulnerable to the development of drug resistance, since having to cross
the border frequently means that reliable adherence to the medication is
difficult.

For those who are lucky enough to be able to afford ART on the private
market, better advice and support needs to be available. Private
practitioners are not always properly trained in prescribing medication
for HIV/AIDS, which can cause serious problems for the patient. Therefore,
proper training in HIV/AIDS care and treatment, supported by the provision
of free-of-charge treatment, should be encouraged through the private
sector.
To make scaling-up possible the Government of Myanmar desperately needs to
invest more in its health infrastructure and specifically allocate funds
to tackle the HIV/AIDS crisis. Likewise, the international community needs
to provide increased support similar to that allocated to HIV/AIDS
programmes in other developing countries and in line with the needs.

Alongside the Government of Myanmar?s need to redouble its efforts in
scaling-up ART provision, it also needs to better facilitate the
international community?s supporting role. Specifically, it should remove
the constraints faced by NGOs which hampers them from implementing
HIV/AIDS programs and ensure improvements in bureaucratic procedures such
as the signing of agreements and import of goods.

In the year 2000, 189 member states of the United Nations, including
Myanmar, committed to working towards achieving the Millennium Development
Goals, including the aim to ?Achieve universal access to treatment for
HIV/AIDS for all those who need it, by 2010?. As it stands, this remains a
far cry from becoming a reality in Myanmar. It is the responsibility of
all actors, national and international to stand-by their commitment to HIV
sufferers in Myanmar and urgently scale-up HIV/AIDS services ? most
importantly ART, to put an end to the needless suffering and waste of
life.

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Myanmar faces 24,000 AIDS deaths for lack of antiretroviral drugs
November 25, Deutsche Presse-Agentur

An estimated 24,000 people will die of HIV/AIDS in Myanmar next year
unless the international donor community is willing to provide funds for
antiretroviral drugs (ART), a medical group warned Tuesday. "Myanmar has
about 240,000 people with HIV/AIDS, and of them about one-third need
antiretroviral treatment without which they cannot survive," said Frank
Smithius, the head of Medecins Sans Frontier/Holland, which treats
patients with ART in Myanmar.

The groups is providing ART to 11,000 patients while the Myanmar
government, the United Nations and other non-governmental groups are
supplying another 4,000.

"It's not enough, when 75,000 people need ART," said Smithius. "It is
estimated by the UN and Myanmar government that 24,000 people will die if
nothing is done in the next year."

Myanmar, which is run by a military junta that is condemned in the West
for its atrocious human rights record and failure to introduce democratic
reforms, is the second-lowest recipient of overseas development aid
worldwide at 3 dollars per capita.

The Myanmar government spends a estimated 0.3 per cent of its gross
domestic product on health, one of the lowest rates worldwide.

In 2008, it allocated the equivalent of 0.7 cents person on healthcare, of
which about 200,000 dollars was allocated to treatment of HIV/AIDS
patients, an MSF report released Tuesday said.

The health care organization has been operating in Myanmar since 1993. It
said it spends about 300 dollars per patient for ART in Myanmar, or about
3.3 million dollars to treat 11,000 patients.

Smithius said it had no additional funds to treat the remaining 60,000
HIV/AIDS patients and called on the international donor community to
assist in dealing with the pandemic.

An estimated 18 million dollars will be needed to treat the HIV/AIDS
patients currently deprived of antiretroviral treatment.

International donors are often reluctant to send aid to Myanmar for fear
the funds will be diverted to the government, which faces strict economic
sanctions from both the US and Europe.

"If we can guarantee that we have been able to deliver medicines directly
to the patients, then there is no reason to not provide aid to Myanmar,
and at MSF we can make that claim," said Smithius.

He said the group runs 25 HIV/AIDS clinics inside Myanmar and has
government permission to import antiretroviral drugs tax free.