November 16, 2011

An MSF outreach counselor in southern Myanmar travels village to village as part of the effort to treat HIV/AIDS and HIV-TB co-infection in the country.



Myanmar 2011 © Veronique Terrasse/MSF

Conducting patient outreach in Myanmar.

Dawn is just breaking when Doctors Without Borders/Médecins Sans Frontières (MSF) counselor Aung Hein Maw begins another day of traveling through the Dawei and Myeik districts in southern Myanmar. In the early morning mist, one can just make out the silhouettes of palm trees and women working in the paddy fields. As the driver steers around the potholes, Maw checks his list of patients to visit. Most of them are "defaulters," or patients who were diagnosed with HIV or TB-HIV co-infection at the clinic but who either failed to come back for their appointment or who have had problems adhering to the treatment.

This is troubling for many reasons. For people living with HIV, TB is the most common opportunistic infection, and the main cause of death. When patients first start on a TB treatment regimen, they should come at least once a month to the clinic so that staff can monitor their progress. However, they don’t always come. “We go and find them in their villages and offer extra support for them to come back for their appointment, then we follow up and ensure they are taking their drugs correctly,” explains Maw, “but we also visit patients when they are at a critical point of their treatment or are experiencing side effects and need more support.”

Treating TB-HIV co-infection is a challenge when dealing with a mobile population. In Dawei, which is home to many migrant workers, MSF runs a HIV clinic and has outreach counselors who play a key role in helping patients adhere to the treatment, which is critical to their recovery. There are currently four counselors working in villages in Dawei and the neighboring district of Myeik, where together they track around 300 patients.

The drive from the Dawei clinic to these villages can take several hours; the roads are not good. Distance is one reason why patients fail to come back. MSF covers transport fees when patients are too poor to pay themselves, but in most cases there are other reasons why patients interrupt their treatment. “Sometimes they don’t understand the disease well, or how to take their pills," says Maw. "Sometimes they find it hard to come, or they need to work. We had cases where people were in denial or scared of discrimination; other times it can be because of the side-effects the drugs can cause."

Little Understanding of HIV/AIDS and TB

The population in the districts is poor and made up mainly of fishermen and day laborers working in paddy fields or rubber plantations. Most have little understanding of HIV/AIDS or TB.

Maw’s first patient, who we will refer to as “S”, is a man in his fifties. Sitting on the floor of his traditional wooden house, they discuss together how the treatment is going, and Maw counts the pills that are left to ensure the right number has been taken.

When S fell sick with TB he remained bedridden for the first three months of his treatment. Although in much better health today, he hasn’t been able to return to his job as mechanic on a fishing boat, and he's being supported by his daughter and son, who both work in Thailand. “When I first got sick I went to a private clinic, and we had to use all our savings to pay the fees," says S. "So it’s very important for me to be receiving free treatment now."

“One of the most common reasons for TB patients to default on treatment is because after a while they feel better and think they are cured,” explains Maw. “They rush back to work and stop coming to the clinic. We really have to explain that it’s very dangerous and could lead to a much more severe form of the disease, drug-resistant TB, where treatment takes at least eight months.”

The Biggest Provider of ARVs

The HIV prevalence rate in Myanmar is estimated to be more than one percent, and the country has one of the highest HIV/TB co-infection rates in southeast Asia. An estimated 250,000 people are thought to be HIV positive and very few can access antiretroviral (ARV) treatment through the Ministry of Health. MSF is currently the biggest provider of ARV medication in the country, with more than 18,000 patients receiving treatment.

While focusing on direct medical care for people living with HIV/AIDS, MSF also offers general health education and helps prevent the transmission of the HIV virus through voluntary testing and counseling and mother-to-child-transmission prevention programs. Other services include treatment of sexually transmitted diseases as well as psychological and social support to patients.

MSF also offers technical assistance and training for HIV/AIDS care programs in hospitals, health clinics and homes. Programs are implemented in cooperation with the National Aids Program (NAP), UNAIDS, WHO, the National TB Program, and the National Health Laboratory.