Lives in thebalance:the urgent need for
HIV and TB treatment
in Myanmar

Photos: Greg Constantine

MSF WOULD LIKE TO THANK ALL THE PEOPLE THAT SHARED THEIR EXPERIENCES WITH
US. WITHOUT THESE TESTIMONIES THIS REPORT WOULD NOT HAVE BEEN POSSIBLE.
UNLESS OTHERWISE INDICATED ALL PATIENT NAMES HAVE BEEN CHANGED.

MéDECINS SANS FRONTIèRESART AND TB TREATMENT PROVIDED
BY MSF IN MYANMAR
ART figures are total figures since MSF started treatment
in 2003. TB figures are as of end of 2011 (TB treatment isusually six months for drug resistant TB, and two years for
MDR-TB).

Executive Summary:Lives in the Balance: the need for urgent HIV and TB
treatment in Myanmar
5 875 ART and
1064 TBThe UN estimates that over the last few years between 15,000 – 20,000 people living with HIV die
annually in Myanmar, because of lack of access to urgent lifesaving anti-retroviral therapy (ART).1
Lives in the Balance outlines the situation for people affected by HIV and TB, with a special focus on
multidrug-resistant TB (MDR-TB), in Myanmar today. It calls for urgent funding and assistance tobe made available by the international donor community to help Myanmar close the devastating gap
between people’s need and people’s access to treatment for HIV and TB.

3 494 ART and
396 TBAn estimated 120,0002 people living with HIV/AIDS are in need of lifesaving ART, in Myanmar. In 2010,
according to national estimates, less than 30,000 of these received it.3
Meanwhile, TB prevalence in Myanmar is nearly three times the global average, and the country has
high levels MDR-TB4 The World Health Organization (WHO) estimates that there are 9,300 new casesof MDR-TB in Myanmar each year. By 2010, 192 MDR-TB patients had been started on treatment.5
Unpublished figures indicate that by the end of 2011, this had increased to over 300.6 This remains far
short of what is needed.

6 23 ART and
149 TBIn 2011, following a five year absence – the Global Fund to Fight AIDS, Tuberculosis and Malaria’7
restarted in Myanmar (in Round 9). The money allocated was crucial to laying the foundationsfor Myanmar’s efforts to provide treatment for HIV and TB. In expectation of further funding, theMyanmar Ministry of Health, and Non-Governmental Organisations (NGOs) have started to makecredible efforts towards scaling up treatment.
The loss of the anticipated funds for HIV and TB treatment is a tremendous blow to Myanmar, the least
developed country in Southeast Asia.8 And one of the lowest recipients of Official Development Aid in
the world.

1 1173 ART and 1382
TB and 72 MDR-TB –pilot project with the
Myanmar Ministry of
HealthMSF in Myanmar
MSF provides health care in Shan, Rakhine and Kachin states, as well as
in Yangon and Tanintharyi regions. Working closely with local communities
and the Ministry of Health, MSF runs a network of HIV/Aids clinics andprimary health centres, providing free, quality medical treatment including
malaria treatment and maternal healthcare to people who lack access tohealthcare in rural and urban areas. Just over 23,000 HIV patients receive
ART from a network of 23 clinics, and 6,000 more are due to start on
the lifesaving treatment in 2012. Services include counselling, testing,treatment of opportunistic infections, nutritional support, health educationand the provision of drugs.
In addition MSF provides TB treatment in the context of its HIV programmes
and providing free diagnosis, treatment and counselling to TB patients.
Approximately 3,000 patients were enrolled in 2011, with just over 70
being treated for multi-drug resistant TB (MDR-TB). MSF has been working
in Myanmar since 1992.

HIV in Myanmar today

Myanmar has some of the lowest coverage rates for ART in the world. ART not only saves lives. It is now
proven to be a critical tool for the prevention of HIV.9

2 232 ART and
416 TB

Médecins Sans Frontières (MSF) is the biggest provider of ART in Myanmar. With more than 23,000
patients on lifelong ART, and with over 6,000 new patients to be enrolled in 2012, we are pushing thelimits of our capacity.
MSF always strives to provide ART across our projects in line with international standards. In Myanmar,
however, faced with overwhelming numbers of people in need of HIV treatment, and the few alternative
sources available for them, MSF – like everyone else fighting HIV/AIDS in Myanmar – has to maketough choices about who we can treat. And who we can’t.
Expected funds from the Global Fund’s Round 11 would have paid for 46,500 additional patients on

1
2
3
4
5
6
7
8
9

UNAIDS, Report for the Global AIDS epidemic 2010 http://www.unaids.org/documents/20101123_GlobalReport_em.pdf
UNAIDS, WHO, UNICEF. Towards Universal Access Progress Report 2010 http://www.who.int/hiv/pub/2010progressreport/full_report_en.pdf
Myanmar Ministry of Health National Strategic Plan for HIV/AIDS in Myanmar, Progress Report 2010
WHO, Myanmar: Health Profile 2009, http://www.who.int/gho/countries/mmr.pdf
WHO, Global Tuberculosis Control 2011 http://www.who.int/tb/publications/global_report/2011/gtbr11_a2.pdf
Figures will be published by the Myanmar Ministry of Health / WHO in 2012
The Global Fund to Fight AIDS, Tuberculosis and Malaria was created in 2002. http://www.theglobalfund.org/en/
UNDP Human Development Report - International Human Development Indicators, 2010, http://hdrstats.undp.org/en/indicators/62006.htm
M.S. Cohen et al. Prevention of HIV-1 Infection with Early Antiretroviral Therapy. New England Journal of Medicine. DOI: 10.1056/NEJMoa1105243 (2011).

3

MéDECINS SANS FRONTIèRESTo prevent the unchecked spread of MDR-TB, exacerbated by HIV and a lack of availability of diagnosis
and treatment, a significant mobilisation of resources is needed. Instead anticipated funding isthreatened and with it, tens of thousands of lives.
A defining moment

The cancellation of Round 11 means that there will be no new funding opportunities to expand
treatment for HIV/AIDS or for TB and its drug-resistant forms until 2014.
Diseases don’t respect such delayed timelines. HIV and TB will continue to spread – unchecked – inmany areas. The time to treat them is NOW.
The maths is simple. Rapidly scaling up HIV and TB treatment now will prevent further transmission
and save both lives and money. Less people infected means less lives lost, and less people in need oftreatment.
This is a defining moment. Recent political reforms in Myanmar have been reciprocated by greater
engagement from the international community. Donors have a real opportunity, and responsibility, tohelp build on those foundations laid to address the gap between need and access to treatment for thoseliving with HIV and TB in Myanmar.
Tens of thousands of lives are hanging in the balance in Myanmar. For these people, the decisions taken
by donors will mean the difference between life and death.
Recommendations:

By improving access to ART in Myanmar, and supporting further efforts to prevent transmission,
HIV in Myanmar can be stopped in its tracks.

• International donors must help ensure that the planned scale-up of HIV, TB and MDR-TB treatment
goes ahead. They can do this by:- Increasing funding, both bilateral and multilateral, for HIV and TB programmes in Myanmar.
- Providing additional funding for the Global Fund in 2012, and actively encouraging other
donors to do the same.
- Supporting the Government of Myanmar in taking the necessary steps to facilitate the planned
scale up of HIV and TB treatment.

Meanwhile, another – often linked – crisis is raging. Tuberculosis.

• The Global Fund must ensure adequate funding allocations for Myanmar.

HIV attacks the immune system. In doing so it leaves the body open to infection. In Myanmar, as
in many developing countries, one of the first infections to take hold is TB. An HIV crisis therefore
inevitably means a TB crisis.

• International NGOs must play their part, and increase support for HIV and TB treatment in Myanmar.

ART, helping to bring total coverage close to 100,000 by 2018.10

A 2010 survey by Myanmar’s National TB Programme in conjunction with the WHO found a TB disease
burden two times higher than anticipated.11 Based on the survey, estimates of the number of cases in2010 may be as high as 300,000. Twenty percent of these cases are people living with HIV.12
A person with active but untreated tuberculosis can infect 10 – 15 other people a year.13
Multidrug-resistant TB has the same airborne transmission as non-resistant TB, but is more lengthy
and complex to treat, and difficult for patients to tolerate. It takes around two years to treat an MDR-TB
patient, compared with the usual six months for non-resistant TB patients. During this time, patients
have to take an even bigger cocktail of drugs, many with severe side effects. MDR-TB is a serious andemerging threat in Myanmar.
Perfectly healthy people can contract MDR-TB.

10
11
12
13

Global Fund Round 9 is expected to help ART coverage reach 50,000 people, leaving a gap of around 70,000 which Round 11 was crucial to helping to close.
WHO Country Office for Myanmar http://www.whomyanmar.org/en/Section23/Section30_232.htm
WHO, Global Tuberculosis Control 2011, http://www.who.int/tb/publications/global_report/en/WHO, Tuberculosis Fact sheet N°104 November 2010, www.who.int/mediacentre/factsheets/fs104/en/• MSF is encouraged by the recent efforts by the Government of Myanmar to increase the health budget
and hopes this will continue. The Ministry of Health needs the resources to provide necessary healthcare to the population, inclusive of HIV and TB treatment.
• MSF asks the Government of Myanmar to continue to support the process of decentralising lifesaving
ART and MDR-TB treatment by facilitating increased geographic access, and through simplifying
operational constraints such as importation procedures.

5

MéDECINS SANS FRONTIèRES

Introduction“Our patients are very sick. Too many of them are dying because they start treatment
too late” – MSF doctor, Myanmar
In November 2011, the Global Fund to Fight AIDS, Tuberculosis and Malaria14 cancelled its next round– (Round 11), originally due to start releasing funds in 2012. Tens of thousands of lives in Myanmar now
hang in the balance.
In 2008, Médecins Sans Frontières (MSF) – which currently provides the majority of all HIV treatment
in Myanmar – released A Preventable Fate.15
The report highlighted the HIV/AIDS crisis in Myanmar for the first time. This follow-up reportoutlines the situation for people affected by HIV and TB, with a special focus on multidrug-resistant TB(MDR-TB), in Myanmar today.
An estimated 120,00016 people living with HIV/AIDS are in need of lifesaving antiretroviral therapy(ART), in Myanmar. In 2010, according to national estimates less than 30,000 of these received it.17
Over the last few years the UN estimates that between 15,000-20,000 people have been dying annuallyin Myanmar because of a lack of access to ART.18
Meanwhile, TB prevalence in Myanmar19 is nearly three times the global average. The number of people
living with TB may be as high as 300,00020, of which around 20 percent are thought to be HIV positive.21
MDR- TB has the same airborne transmission as non-resistant TB, but is more lengthy and complex totreat, and difficult for patients to tolerate. Myanmar is among the 27 countries with the highest rates of
MDR-TB in the world. The World Health Organization (WHO) estimates that there are 9,300 new casesof MDR-TB in Myanmar each year.22 By 2010, 192 MDR-TB patients had been started on treatment.23
Figures for 2011, not yet published, indicate that the total number of people that have been receiving
treatment has increased to just over 30024.
Support from the Global Fund in Myanmar re-started in 2011, following a five-year absence from thecountry. The money allocated at that time (through Round 9) was crucial to laying the foundations for
Myanmar’s efforts to provide treatment for HIV and TB. But a devastating gap remains between people’s
need and people’s access to treatment.
The Global Fund’s Round 9 to Myanmar is expected to help 50,000 people access ART by 2015, a
significant increase, but it still leaves 70,000 people in need of the lifesaving treatment. Round 11 would
have been crucial in helping to close the gap: expected funds would have paid for 46,500 additional
patients on ART, helping to bring total coverage close to 100,000 by 2018. The funds were also
anticipated to put 10,000 MDR-TB patients on treatment.
Donors, however, have failed on their commitments. Faced with a funding shortfall, the Global Fundboard decided to cancel Round 11. If urgent financial assistance is not made available for Myanmar,
the consequences will be devastating.
The loss of the anticipated funding for HIV and TB scale-up and MDR-TB treatment is a tremendous

14 The Global Fund to Fight AIDS, Tuberculosis and Malaria, was created in 2002. http://www.theglobalfund.org/en/
15 MSF, A Preventable Fate – The failure of ART scale-up in Myanmar, http://www.doctorswithoutborders.org/publications/reports/2008/Preventable-Fate.pdf
16 UNAIDS, WHO, UNICEF. Towards Universal Access Progress Report 2010 http://www.who.int/hiv/pub/2010progressreport/full_report_en.pdf
17 Myanmar Ministry of Health National Strategic Plan for HIV/AIDS in Myanmar, Progress Report 201018 UNAIDS, Report for the Global AIDS epidemic 2010www.unaids.org/documents/20101123_GlobalReport_em.pdf
19 Myanmar is among the 22 TB high burden countries, the 27 MDR-TB high burden countries and the 41 TB/HIV high burden countries in the world (WHO).
20 WHO, Myanmar: Health Profile 2009, http://www.who.int/gho/countries/mmr.pdf
21 ibid22	WHO Multidrug and extensively drug-resistant TB) 2010 GLOBAL REPORT ON SURVEILLANCE AND RESPONSE http://whqlibdoc.who.int/publications/2010/9789241599191_eng.pdf
23 WHO, Global Tuberculosis Control 2011, http://www.who.int/tb/publications/global_report/en/
24 Figures will be published by the Myanmar Ministry of Health / WHO in 20127

blow to Myanmar, the least developed country in Southeast Asia. 25It is the poorest people, those with theleast access to healthcare, who will pay the highest price.
This is a defining moment. Recent political reforms in Myanmar have been reciprocated by greater
engagement from the international community. Donors have a real opportunity, and responsibility, tobuild on those foundations and help address the gap between need and access to treatment for HIV and
TB sufferers.
Living with HIV in Myanmar

The adoptive grandmotherPhoe Lone 12: “I go to school, I am in grade four. Maths is my favourite subject. When I grow up I want to be a seaman.
Sometimes I feel lonely. One of my friends saw me while I was taking my [ART] drugs. That boy told the others.”
Thida Win 58: “I heard that both of his parents had died. He had nobody to care for him, so I decided to save one life.
I found out he was HIV positive when he was two years old. He was not feeling well, so I took him to the doctor. At
that time he couldn’t walk – he would try, but the fever would stop him. His ART started when he was three years old.
Now he is very healthy; he only gets sick once in a while. I am very old, I don’t know how much longer I will be alive. I
want to be able to support his education so he can stand up in the future. In the future I hope that he can stand up for
himself.”“I want to see the treatment be accessible for every patient in Myanmar. I wantpeople to stay alive by taking treatment, like us.” – 30-year-old female HIV patient, whose
husband and youngest child are also HIV-positive.

Myanmar has some of the lowest coverage rates for ART in the world. 26An estimated 85,000 people
living with HIV still lack access to the lifesaving treatment.27
While not a cure, ART is quite literally lifesaving for the millions of people alive and on treatment today.
A 2008 study showed that a 20-year-old starting ART between 1996 and 2005 can expect to live another43 years on average.28“When I first knew my status, I felt hopeless and felt there was nothing I could do. My
life was dead at that time. I didn’t know how to live, or how to cope. Now that I havereceived treatment I can work again – I even came third in Myanmar’s music idol in2010” – 32-year-old man living with HIV.
25 UNDP Human Development Report – International Human Development Indicators, 2010, http://hdrstats.undp.org/en/indicators/62006.htm
26 UNAIDS, Report for the Global AIDS epidemic 2010, http://www.unaids.org/documents/20101123_GlobalReport_em.pdf
27 Taking into account the Myanmar Ministry of Health/UNAIDS preliminary 2011 figures for ART treatment in Myanmar, not yet published - MSF and others estimate that the ART
treatment gap currently stands at 85,000
28 The Antiretroviral Cohort Collaboration. Life expectancy of individuals on combination therapy in high-income countries: a collaborative analysis of 14 cohort studies. The Lancet
372: 293 – 299, 2008.

HIV used to be a death sentence but, with ART people’s immune systems are given a chance to bounceback and fight sickness again. They can return to work; and the fear and stigma surrounding the disease
reduces.
“I am a Buddhist and, according to Buddhism, I need to do good things. If I die, thenI won’t have time to do those things. Now, because of the treatment, I can meditate
two times a day. I can even play football.” – 56-year-old man living with HIV.

10

WHERE ARE THEY NOW
MSF was lucky enough to catch up with two patients featured in the 2008 report and slideshow A
Preventable Fate and see how they were doing in January 2012.

Tharr Gyi
Tharr Gyi was nine years old when he was orphaned by AIDS. Found fending for himself in a market after his parents died, he
was later reunited with his grandparents. His grandfather has since died. Now 14, he is doing very well physically, but has otherdifficulties to cope with. On the day we meet him, his grandmother has just been diagnosed with cancer.
“I’ve been on ART now for probably six years. After the treatment, I can eat more, I can sleep well. I enjoy coming to the clinic. I
have to come to the clinic regularly because I need to stay alive. I think ART is very important for my life.
I went to school until I was seven, then I had to quit after I lost my mother. I have no money to go back to school. At the moment,
I’m selling ice cream and dried fish. In the morning, I have to go to the ice cream factory, collect the ice cream bars and then I
go to New Wat market. In the afternoon, I sell dried fish at Bayint Naung market. I take the bus and then I have to walk for 30
minutes. I never get a holiday from selling ice cream bars and fish.
Last week I went to the pagoda on a bus. I went with my uncle, aunties and grandma. I enjoy going to the pagoda. It makes me
feel very peaceful.
When I am older, I would like to be a wealthy man, and I would like to donate all of my wealth to the poor.”

Zar Ni Aung (real name) is a singer and a volunteer with the HIV awareness group, Myanmar Positive.
“My mission is to raise awareness in the Burmese community, and also to reduce discrimination among the community,
and to get treatment on time for anyone who needs treatment. If I need to shout, I am ready to shout.
I have been taking ART since 2006. In 2006 my body weight was 40 kg, my CD4 count was 20. I felt always sick withfever. I was very depressed at the time. I felt hopeless and felt there was nothing I could do. My life was dead at thattime. I didn't know how to live, how to cope. After getting the treatment, my life changed completely. Sometimes, I evenforget that I am HIV positive.
Since I saw you last, I have worked a lot. I was a volunteer at an MSF clinic, and I provided peer-to-peer education andpsychological support to peer groups. In 2009, with Myanmar Positive, I visited around the countryside, especially invillages, to talk about HIV/AIDS in order to reduce the stigma.
I’m really interested in singing. In 2010 I won third prize in a song contest organised by Myanmar Music Idol. I also took
part in HIV awareness raising by disclosing my status at an event organised by Myanmar Christian Council.
I was really lucky last year, I travelled to Korea to talk about HIV and I was able to travel to Thailand for a civic
development education conference in Chiang Mai. I also worked as a facilitator in HIV-related workplace policy
organised by the UN CARE programme. I provided a lot of training to UN staff to enhance their awareness among thestaff.
This is the great benefit of ART treatment: good outcomes. If I didn’t get ART, I could not do these kinds of social
activities. That’s why receiving ART from MSF was a milestone in my life.”

Tharr Gyi with hisGrandfather in 2008.

MéDECINS SANS FRONTIèRES

Impossible choices

Faced with overwhelming numbers of people in need of HIV treatment, MSF – like everyone elsefighting HIV/AIDS in Myanmar – has to make tough choices about who we can treat. And who we can’t.
MSF has had to stop enrolment at various times since starting to scale up in 2003, and in many areas weare currently forced to conduct a desperate form of triage. We simply do not have the capacity to manage
the roll-out of HIV treatment on such a large scale. As a result, our doctors are forced, on a daily basis,
into the agonising decision not to provide ART to patients who, according to WHO standards, should
receive it, but who are not as sick as the person next to them in the queue.
A CD4 count is a test used to measure the immune system’s suppression – an indication of how far the
HIV virus has progressed, helping doctors to determine when to start the next stage of treatment. The
lower the CD4 count, the more advanced the HIV infection is.

According to WHO guidelines, anyone with a CD4 count lower than 350 should
receive ART.
A CD4 count is a test used to measure the immune system’s suppression – anindication of how far the HIV virus has progressed, helping doctors to determine
when to start the next stage of treatment. The lower the CD4 count, the moreadvanced the HIV infection is.
In 2009, the WHO criteria changed from CD4 200 in developing countries to CD4 350,
as increasing evidence proves that the earlier you start patients on ART, the greater
the chances of their survival. For example, a recent study shows how starting ART
at an earlier stage in the HIV infection (when the CD4 count is higher) decreases therate of death by 75 percent in HIV-infected adults as well as decreasing the incidenceof tuberculosis by 50 percent.30

HIV Treatment 2009
(Unaids Report for the Global AIDS epidemic 2010)100
90

MSF always strives to provide ART across our projects in line with international standards. In Myanmar,
however, the high numbers of people in need of treatment, and the few alternative sources for them,means we are unable to accommodate all those people in need.

80
70
60

MSF provides ART to more than 23,000 HIV patients in Myanmar (by end 2011), and with over 6,000
new patients to be enrolled in 2012, we are pushing the limits of our capacity.

50
40

In some areas, MSF has no choice but to make the extremely difficult decision only to include the sickest
patients, those with a CD4 count of less than 150, or that have clinical signs and symptoms indicating alife-threatening progression to AIDS

30
20
10
0

MyanmarVietnamThailandCambodia

Laos

Figure 1. This graph was created using UNAIDS data.29“MSF cannot yet provide me with ART. I’m only taking anti-TB treatment. But it is
not enough. After two to three days I get diarrhoea again. After eating, everything isgone by diarrhoea. I have no energy.” – 38-year-old man living with HIV, currently unable to accessART.

Our doctors are under enormous pressure. It is horrific for them to have to turn patients away.
“In our minds, we are still worried about the future of ART. This worry is not only forus, but also for the people who still have not received treatment.” – 25-year-old female HIVpatient whose husband and youngest child are also HIV positive.

“For me, the worst part of my job is to have to tell people that they should be getting
treatment but that we can’t give it to them. It really hurts to do this.” – MSF clinic
manager.

29 UNAIDS, Report for the Global AIDS epidemic 2010, www.unaids.org/documents/20101123_GlobalReport_em.pdf

30 Early versus Standard Antiretroviral Therapy for HIV-Infected Adults in Haiti New England Journal of Medicine 363:3 July 15, 2010 http://www.nejm.org/doi/full/10.1056/
NEJMoa0910370

13

14

MéDECINS SANS FRONTIèRESUNABLE TO ACCESS TREATMENT. TWO PATIENTS WHOSE CD4 COUNTS ARE
BELOW CD4 350 BUT ARE NOT YET ABLE TO ACCESS ART

The flip-flop maker
Maung Myint, 38, has a CD4 count of less than 200. While we talk, he clings to his water bottle, taking frequent sips ofthe liquid mixed with rehydration salts.
“I used to make flip-flops, with a technique I inherited from my parents. They were experts in making flip flops andfootball shoes. But then I started to get fever and then diarrhoea. That’s why I went to the government hospital and theygave me an HIV test, and I found out I was HIV positive.
When I found out I was HIV positive I was really sad and upset. I thought that there was no treatment for HIV. I thought I
would die in one day.
I was living at my brother’s house. But my brother’s wife is very afraid of HIV and they have children. So that is why shecannot accept me staying with them. She used to check my skin to see if there were ulcers. And she told me to stayaway from her children. I felt so insecure that I had to leave.
I still have contact with my brother’s family. They help me with the transportation charges to get to the clinic and also alittle money for food. I hate to have to go to my brother’s family and ask for support. But I had to. I really am sad that I
can’t make flip-flops. I am an expert in making them and I can earn a lot of money from this, but I can’t do it anymore.
So I have to ask others for help but I don’t want to. I hate the situation I’m in.
MSF cannot yet provide me with ART, so I’m only taking anti-TB treatment. But it is not enough. Before I got sick I
was very healthy – I really liked to run and play sports. But after I was infected I couldn’t do anything. After eating,everything is gone by diarrhoea. I have no energy. Six months ago my body weight was 50 kg. Now it is just over 40 kg.
I believe ART will be able to give me a normal life. I dream to be healthy again, to own a flip-flop making business. I
don’t know what will happen if I can’t get ART. I don’t know what I will do.”Kyaw Kyaw is 21 years old but he looks 14. He has a CD4 of 168. He is recently divorced and currently lives with hismother and grandmother. He found out his HIV status in January 2012, but is unable to access treatment.
“It started with a fever. And I had pains all over my body. I was sick a lot. I had diarrhoea a lot. And also I had pain in
my belly and stomach disease and also chest infections. Before, I weighed just over 54 kg, now I weigh 23 kg. I didn’t
eat for almost a month. I have soft drinks, tea. Some people in my neighbourhood suggested I go to MSF and have ablood test.
I believe I contacted HIV from my ex-wife. She is as a commercial sex worker, but at that time I didn’t know that.
I had to stop working nearly two months ago. I am lucky that my grandmother – a traditional bath attendant – is able tohelp support me financially.
I understand very well [the MSF criteria]. I saw a lot of people who are very sick, and MSF cannot provide help toeveryone. So I will get my ART when my CD4 is below 150.
Honestly, Myanmar is very poor and we can’t afford everything. We still need to get support, but we haven’t gotten
enough support. So I hope everyone who needs ART can receive complete treatment.”

15

New mother

The factory worker

Chit Chit Yee is 34 years old and a former karaoke bar hostess. She has a ten-week-old baby and is HIV-positive.
“I came here for antenatal care when I was seven months pregnant. At that time I found out I was HIV positive. After I
found out, my husband left. Both of my parents died. I only have two older brothers. My brothers don’t know about mystatus. I’ve now been taking ART for one month.
I’m worried about my baby. I am taking medication to protect my baby from getting HIV positive. The counsellor andthe nurses gave me information about the transmission of the disease from mother to child. Even if you are getting the
medication, there still is a very low chance.”

Twenty-seven year old Ko Ko Naing knows all about the consequences of HIV. Two of his close friends died of thedisease. He discovered his own status in January 2012, after having a blood donation refused. Before that, he did notknow that ART existed. He is – as yet – unable to access ART.
Ko Ko Naing is in the clinic with his wife, who is getting an HIV test done. He is fearful for her.
“Since finding out I have HIV, I don’t really deal with other people apart from my wife. After I disclosed my status to mywife, she cried a lot. She cried for one day and one night. She said that if she finds out she is HIV positive, we will work
together and save money in case our health is not ok. She said, ‘I’m not going to have children.’ This is the worst thing,that we cannot have children.
I told her that, if she gets a negative result, she can divorce me and go back to our village. But she refused. She said shewould stay with me, even if she is negative.
I cannot get the drugs from this clinic because they don’t have enough supply. With a smiling face, my wife says to me,‘You don’t have drugs,’ and, ‘You are not cured,’ but inside I know she is crying.
My friends had not known about ART, even though they were HIV positive. Had they been able to get the treatment,
maybe they be alive today. At one point they got sores on their skin and these sores did not heal. There were also
abcesses and puss came out all the time. When people saw this they felt awful, and did not want to deal with myfriends, or with me. By the time my friends found out what it was, they were already at the stage of AIDS, not just HIV. In
the end they died in my arms.”
I am worried what will happen if my work finds out about my status . Once in my factory, someone was found with HIV,and that person got fired straight away.
Later, as we are leaving the clinic, we see Ko Ko Naing again. He looks stunned. Then he smiles and the relief shines
through his face. His wife has just received her results. They are negative.

“Re-starting ART – Ma Khin Win, CD4 count 20, weight 27kg.
“I have known about my HIV status for four years. I arrived at MSF two years ago and started my ART
treatment. I made a big mistake at that time. I didn’t take my ART regularly. After I got really sick, I reallyregretted not taking my ART. I decided to restart my ART treatment and take my medicine, because I am
still young, and I am responsible for raising my daughter, so I should be healthy. So I came back to theclinic.. I ask at the market for donations of money and food as I can’t work anymore, I am too sick. My
daughter helps me all the time with everything. Three months ago, my daughter had an HIV test and thetest was negative. If I die from AIDS, I will leave my daughter alone in this life.”

18

FAMILIES LIVING WITH HIV

Khine Htun, (32, m)Tin Aye (Miss), (30, f) Moe Zaw Hein (4)Father: “I started to know my status in 2008. When I found out I had contracted HIV, physically I still felt fine. But
mentally I collapsed. I had no knowledge or information about HIV treatment. I only knew that there were no drugs for
HIV and I was prepared to die. I was also very afraid that my neighbours would find out about my status.
I’m from Thayawaddy. I was a member of a charity blood donation group. During my last visit for donation they refused toaccept my blood because I have HIV. I am a driver, I was worried about how my status would affect my work.
But since I started treatment, I am able do my job very well. My biggest worry is about my family. We are four family
members in total. My oldest child is a girl – and she is HIV-negative. She is really helpful to us. She always reminds
us to take the pills at 7 o’clock. ’Take the pills on time.’ Not only to us but also to her younger brother. My son is HIV
positive. I feel so guilty because of this. In my hometown, in the past, the HIV knowledge level among the community
was very low, but starting last year, we organised a self-help group.
Mother: “As a mother, I should stand in front of my children very bravely. My future dream is to see my children as
educated people, so we will put a lot of effort to see this happen. We will take ART and we will try to stay healthy. We
will work to earn money and work for the children.
If I didn’t get treatment from MSF, I would always have to stay in bed, maybe I would already have died by now. If I didn’t
get the treatment it would be impossible to achieve my dreams. If I didn't get ART, our family could not enjoy a happylife.
We know from MSF that ART can help us to stay alive. But we are all still very worried about getting ART in the future.
I want to see the treatment available for every patient in Myanmar. I want to see people stay alive by taking ART
treatment, like us.

Ohn Kyaw is HIV positive, and has been wheelchair-bound and unable to work for the past seven years. His wife, Aye Ayeand their two young daughters are also HIV positive.
“In the beginning, I used to get fevers and chest infections all the time – that is why I couldn’t walk. I was always absent
from work, so I was fired. I got worse and worse and could not earn money. I thought I was the only positive one in myfamily. Then MSF invited my family members to the clinic. First my wife found out she was also positive, and then mytwo children. It all started from me.”
“It all started from me. It all started from me. I felt so much regret. I was worried about my children’s future. We have no
relatives, no stable housing. I cannot work anymore. We have nothing.”“I am always struggling to be a good mother.” Aye Aye is speaking now. Her voice is choked and there are tears in her
eyes. “I want to see my children educated. Parents should take care of their children for life. Before starting treatment,
my CD4 level was 10. I couldn’t walk. I looked like a skeleton. Now it is more than 600. Physically I am fine, but in mymind I am not well. I worry about my future accommodation and expenses for the whole family.”
Ohn Kyaw looks up. “I haven’t worked in seven years. All of these things my wife has to worry about: the food, and theschool fees and the living costs. These are my responsibilities. I can’t meet them. This makes me really sad.”
After the interview, the Senior Counsellor tells me that the mother is well known in the clinic. “She is famous in thisclinic, we call her the ‘ iron lady’ because she is so strong, so strong, to hold this family together”

FamilyMother: “I found out I was HIV positive just a monthago. I went to the dentist and he saw problems
in my mouth and told me that I had to go for HIV
testing. I felt so sad when I found out I was HIV
positive; I had no hope to live anymore, now I
understand a bit more I worry less. I give ART to
my son, as a powder, at seven in the morning andseven in the evening.”
Father: “I am originally from Upper Burma so
I have no job in Yangon. When I heard my HIV
status, I felt really sad. Why has this happened tome? I feel really upset for my son’s future and I
worry about his future. I am really happy to hear
the information about ART treatment. I know ART
cannot kill the HIV virus, but with it I can wait to
get a drug that will cure HIV.”MéDECINS SANS FRONTIèRES“Until more treatment becomes available, we have little option but to continue as weare currently; struggling to our maximum capacity to manage the sheer numbers ofdesperately ill patients coming to the clinics, and turning away on a daily basis those
who are not yet sick enough.” – MSF project coordinator, Yangon.
“I wish to get more treatment for Myanmar patients. So that others do not have tofeel as sick as me..” – Woman HIV patient, CD4 count 20.
“Another very sad thing for our staff is when the patients come at a very late stage.
We try very hard. But when they are this sick, even with our best efforts we lose many
patients this way.” – MSF nurse.

ART is prevention“In the past, my son used to have fever all the time, especially during the rainy season. Afterthe treatment, my son’s health condition really improved. Sometimes I feel like he’s actuallystronger than other kids.” – HIV positive woman talking about her four-year-old HIV positive son.
Due to the scale-up of ART, AIDS deaths have declined worldwide, and there have been decreases in overall
adult mortality, as well as infant and under-five mortality. 31ART has also led to fewer children being bornwith HIV and fewer AIDS-related orphans. It has also helped to slow the emergence of infections such as TB.32
ART not only saves lives. It is now proven to be a critical tool for the prevention of HIV. A 2011 study found a
96 percent reduction in HIV transmission among couples in which one partner was HIV-positive and on ART
and the other partner was HIV-negative.33
33-year-old Tun Maung was a trishaw driver. With full-blown AIDS and TB, he has a long road ahead of him. His mother
Kyu Kyu has moved to Yangon from her village five hours away to look after him. Despite the severity of the situation
she is upbeat as the treatment takes effect. “He walked yesterday, it was incredible – it will be a long recovery but I
have so much hope now”.
Tun Maung and his mother will need to stay in Yangon for a minimum of six months. There is nowhere closer to theirhome where he can access the treatment he needs.

But, with our limited capacity, the only other alternative would be to enroll less sick patients fortreatment – who have a greater chance of survival – over the sicker ones. And turning away the sickest
people would feel the less ethical of an already impossible choice.
In the meantime, those with CD4 counts of between 150 and 350 must wait and watch their bodies
deteriorate, hoping that there will be a slot for them in one of the hospitals or clinics before it’s too late.
“They [an MSF Yangon clinic] said that ‘we can only provide drugs to those whose
immune level is below 150. The reality is that we should provide drugs for those
whose immune level is at 350’. When I heard this. I was really upset and worried
about my future. I wasn’t only worried about myself, but I saw so many sick people in
the waiting area and I was worried about them too.” – 27-year-old man living with HIV
As they wait, many patients face stigma and discrimination at home, in their communities, and at work.
“I used to live at my brother’s house, but my brother’s wife is very afraid of HIV. She
used to check my skin to see if there were ulcers or pus discharge or something likethat. And she told me to stay away from her children. I felt so insecure that I had toleave.” – 38-year-old man living with HIV, CD4 count of 200, unable to access ART.
It is critical that more treatment for HIV is made available in Myanmar. Until recently, there wereencouraging signs that this would happen in coming years. Now, in some areas, MSF and others willcontinue to be forced to try to save lives far later than they should.

Improved situation, and cautious optimism

For HIV/AIDS there is no question that the situation in Myanmar has improved from just a few years
ago, when virtually no ART treatment was available.
Prior to the commitment of funds from Global Fund Round 9 for 2011-2015, the combined efforts ofinternational NGOs, and the Government of Myanmar reached less than 20 percent of people in need of
ART in Myanmar.34
Laudable efforts from initiatives such as the Three Diseases Fund (3DF) 35 helped to cover some of themost urgent needs.
Even so, the devastating treatment gap claimed an estimated 18,000 lives in 2009.36
MSF was lucky enough to catch up with two patients featured in the 2008 report and slideshow A Preventable Fate and see how they were doing in January 2012. The fear of people with HIV was palpable.
But with an increase in funding and the re-entrance of the Global Fund in Round 9, in 2011, scale-up
began. Today, even amongst those unable to access treatment, there is a sense of optimism. Of hope. Evenin the face of adversity.
“Even if you have HIV, you must not get depressed. You have to stay positive, withpositive living. I will get my ART when my CD4 level is below 150.” – 21-year-old man,CD4 count 186, currently unable to access treatment.

31 WHO. Global HIV/AIDS Response: Epidemic update and health sector progress towards Universal Access. Progress Report 2011. http://www.who.int/hiv/pub/progress_
report2011/en/index.html
32 M.S. Cohen et al. Prevention of HIV-1 Infection with Early Antiretroviral Therapy. New England Journal of Medicine. DOI: 10.1056/NEJMoa1105243 (2011).
33 M.S. Cohen et al. Prevention of HIV-1 Infection with Early Antiretroviral Therapy. New England Journal of Medicine. DOI: 10.1056/NEJMoa1105243 (2011).
34 UNAIDS. Report for the Global AIDS epidemic 2008, http://www.unaids.org/en/dataanalysis/epidemiology/2008reportontheglobalaidsepidemic/ Accessed 11th February 201235 To help fill the gap left by the Global Fund’s departure from Myanmar in 2005, a US$138 million multi-donor consortium comprising the European Commission and the Governmentsof Australia, the Netherlands, Norway, Sweden and the United Kingdom was set up in October 2006 to help tackle HIV, TB and Malaria. Denmark joined the 3DF in 2009. In 2012, the3DF will become the 3MDG fund which will primarily focus on funding maternal and child health care with some limited funding for HIV/AIDS and TB.
36 UNAIDS, Report for the Global AIDS epidemic 2010, www.unaids.org/documents/20101123_GlobalReport_em.pdf Accessed 11th February 2012

21

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Since 2008, MSF has more than doubled its capacity to treat HIV patients, from 11,000 to 23,000. Several
other NGOs had committed to scale up under Round 11, but they are fully dependent on the availabilityof institutional funds to do this.
Cautious optimism for the future of HIV and TB treatment has taken hold in Myanmar. The donor
community must not allow this hope to turn to despair.
There is a real opportunity being missed here. HIV prevalence rates in Myanmar are relatively low
compared with many other nations. It is lack of access to treatment that makes it one of the most serious
epidemics in Asia.
By improving access to ART in Myanmar, and supporting further efforts to prevent transmission, HIV in
Myanmar can be stopped in its tracks.
MSF data proves feasibility and necessity of ART delivery at primary care level in
Myanmar – Sabapathy et al, to be published in 2012 in the Journal of Acquired
Immune Deficiency Syndrome (JAIDS).
A recent study of the MSF ART programme. due to be published by JAIDS examined treatment outcomes amongst
approximately 6000 patients over nearly 7 years on ART. Despite advanced immune-suppression (46% of patients were in
WHO Stage 4 disease*), very low nutritional status of the majority of patients (54% were severely underweight with a Body
Mass Index <18.5kg/m2), and a high proportion of TB co-infection (62% of patients had a history of TB diagnosis), survivaland retention on treatment of patients was high compared with other similar resource limited settings. The researchersconclude that large scale delivery of anti-retroviral treatment from a primary care level is feasible and call for increased
support for ART in Myanmar.
*For more information on WHO staging criteria see www.who.int/hiv/pub/guidelines/clinicalstaging.pdf

Meanwhile, another – often linked – crisis is raging. Tuberculosis.

A person with active but untreated tuberculosis can infect 10-15 other people a year.37
HIV attacks the immune system. In doing so it leaves the body open to infection. In Myanmar, as
in many developing countries, one of the first infections to take hold is TB. An HIV crisis therefore
inevitably means a TB crisis.
Myanmar is among the 22 countries with the highest rates of TB in the world, with prevalence in
Myanmar more than double the regional average and nearly three times the global average.38
A 2010 survey by Myanmar’s National TB Programme in conjunction with the WHO found a TB disease burden
two times higher than anticipated.39 The Global Fund’s Round 9 funding allocation for TB in Myanmar
was decided on the basis of previous figures for TB prevalence, now known to be highly underestimated.
“We live far from Yangon, a four-hour bus ride and then a five-mile walk from theroad. Transport is very expensive. The doctors have said we should stay another threemonths. But, we can’t afford to do it, we want to go home. My husband died recently– he drowned. I don’t spend any money on myself, just on my son.” – Mother and only
caretaker of an HIV-TB co-infected patient, CD4 count 42, who has had to move to Yangon to get treatment.

These newly estimated figures demonstrated that there may have been up to 300,000 TB cases in
Myanmar in 2010.40 Around twenty percent of these cases are people living with HIV.41Worldwide, TB is
the leading cause of death among people infected with HIV – almost one in four deaths among people
with HIV is the result of TB.42
37
38
39
40
41
42

WHO, Tuberculosis Fact sheet N°104 November 2010, www.who.int/mediacentre/factsheets/fs104/en/ Accessed 11th February 2012
WHO Myanmar: Health Profile 2009, http://www.who.int/gho/countries/mmr.pdf
WHO, Global Tuberculosis Control 2011, http://www.who.int/tb/publications/global_report/en/WHO, Global Tuberculosis Control 2011, http://www.who.int/tb/publications/global_report/en/WHO, Global Tuberculosis Control 2011, http://www.who.int/tb/publications/global_report/en/Ibid
WHO TB/HIV Facts 2011, http://www.who.int/tb/challenges/hiv/factsheet_hivtb_2011.pdf

Ma Moe Moe is 28 years old. She had to come all the way to Yangon to get tested for MDR-TB. She was lucky: her doctor
knew enough to send her to Yangon, and she was able to raise the 50,000 Kyatt (US$ 73) to get there.
“I came to Yangon because the doctor in my home town suspected that I was suffering from MDR-TB, but I could not dothe test in my home town. I came to Yangon with my husband. He works as a blacksmith. I had to leave my children – aboy of seven and a girl of four – with my parents. The journey took two full days and one night. I was referred to the
MDR-TB team, who did tests and found out that I was positive for MDR-TB.
The last year has been horrible. I was on continuous treatment for eight months – it was really painful and I had severeside effects from the tablets. I had to take 13 tablets for breakfast and a pack of PAS granules and then the injections.
In the evenings I had to take the PAS again. I had horrible side effects: heartburn, nausea, joint pain. All the time I was
missing my children.
I was separated from my children for one year. Now my children are both with me. They arrived at the end of 2011. Now
I am really happy.
I have to take MDR drugs for two years. I still take drugs every morning and night, but now fortunately I can toleratethem well. After the first eight or nine months, I became healthy, I got my appetite back. Now I can work in the houseand walk around, go to the market and cook at home. When I complete my treatment, I will go back to my home town.”

The survey showed that most people infected with TB in Myanmar cannot be detected with existing
techniques. Global Fund Round 11 was intended to help Myanmar accelerate case-finding through theuse of new technologies and through proactive efforts at community level.43 In this way, Myanmar hadplanned to boost its ongoing TB control programme and reach the vast numbers of TB patients hiddenfrom view. Now, these efforts are severely threatened.
Multidrug-resistant TB – a serious and emerging threat“Most of the people don’t know what it really means. That is why they have no fear
about MDR-TB. They only fear HIV/AIDS. But this does not make sense. TB istransmitted easily through the air, HIV is not. No one knows who is suffering from
TB. – 38 year old man, co-infected MDR-TB and HIV.
43 In line with WHO’s action framework for higher and earlier TB case detection, Myanmar aims to undertake TB case-finding activities through: using new tools such as GeneXpert (apromising new diagnostic test for TB); country-wide awareness campaigns; working with healthcare providers at community level and mobile team activities in highly prevalent remoteareas to strengthen referral of TB suspected cases.

24

Multidrug-resistant TB occurs when the TB bacilli are resistant to two of the most common anti-TB
drugs, isoniazid and rifampicin.
According to the WHO Myanmar is among the 27 countries in the world with a high MDR-TB burden.44
Resistance can occur when adherence to the required daily dose is poor or patients don’t complete theircourse; when healthcare providers prescribe the wrong treatment, dose or length of time for taking the
drugs; when the supply of drugs is interrupted; or when drugs are of poor quality, as is the case withmany on the private market.
MDR-TB has the same airborne transmission route as non-resistant TB, but is hard to diagnose, andlengthy and complex to treat. It takes around two years to treat an MDR-TB patient, compared with theusual six months for non-resistant TB patients. During this time, patients have to take an even bigger
cocktail of drugs, many with severe side effects.
“In the mornings I used to hate having to take all the drugs – there were so many.
Seventeen tablets, plus a lot of smaller ones, and that’s not including the drugs for
numbness and dizziness.” – 37 year old man, now cured of MDR-TB.
“When I arrived in Yangon, I was suffering from chills and fever and loss of appetite.
After I started treatment, my physical condition really got bad. I had to stay all day
in bed. I had nausea, vomiting and pain from the injections. This continued for eightmonths. All the time I missed my children. It was all horrible.” – 28-year-old Woman, MDRTB patient, 16 months into treatment.

Perfectly healthy people can contract MDR-TB.
Those living with HIV/AIDS are particularly vulnerable. MDR-TB has been shown to be almost twice ascommon in TB patients living with HIV, compared to TB patients who are HIV negative.45 People with
HIV infection are also at greater risk of dying of MDR-TB.
“For MDR it is very, very difficult to be cured. When I was in the hospital I saw othersick people being treated for MDR. Some got kidney problems after they completed
the injection course. Some had hearing problems or oedema, and some went crazy. I
saw these experiences with my own eyes.” – 38 year old man, co-infected MDR-TB and HIV.
At present, there is very limited access to diagnosis and treatment for MDR-TB sufferers in Myanmar.
Round 11 was intended to target new geographic coverage for MDR-TB, with plans for treatment centres
in all states and regions. The plan was to reach a further 10,000 MDR-TB patients over five years. At the
moment, MDR-TB treatment is only officially available in Yangon and Mandalay divisions �, and theclinics that offer treatment have lengthy waiting lists.

The cured patient – Aung Naing Do – completed treatment. 37 years old“Tomorrow will be two months since I finished the treatment, and I’m feeling better every day. I’ve been doing morejobs around the house, not much, but a little. I’m a hairdresser, and I’ve been back at the salon, doing a little bit ofwork. I’m just so happy to be free from the side effects of the treatment. In the mornings I used to hate having to takeall the drugs – there were so many. Seventeen tablets plus a lot of smaller ones, and that’s not including the drugs for
numbness and dizziness.
I started suffering from this illness in 2006, so it’s taken five years for me to get treatment and overcome it. During thattime I had to wait a year from being diagnosed with MDR-TB to getting on the treatment programme. And all that time, I
was feeling worse and getting weaker by the day.
I was bedridden towards the end of the wait, coughing all the time and with constant shortness of breath. I couldn’t
even walk from the clinic to the main road without stopping about ten times. I had to stop working in the hairdressing
salon – I didn’t have the strength even to sweep the floor.

To prevent the unchecked spread of MDR-TB, exacerbated by HIV and the lack of availability ofdiagnosis and treatment, there has to be a significant mobilisation of resources. But instead, the muchanticipated funding is under threat, and with it, thousands and thousands of lives.

I have a tattoo on my hand. It means ‘perseverance’. I got it at a pagoda festival when I was 15 just because I liked thelook of it. But during the wait, and then during the treatment, it took on a new meaning for me. It reminded me that I
had to hold on, have courage and not give up. I really needed that because, when I was finally admitted to the treatment
programme, the side effects were so bad I almost wished I wasn’t being treated.

As with HIV/AIDS, early diagnosis and treatment of MDR-TB is important to increase patients’ chancesof survival. One of MSF’s first patients to complete MDR-TB treatment died soon after finishing thecourse of drugs. Lack of access to the treatment he so urgently needed meant that he started the course
far too late. While waiting to start the course, he had sustained lung damage and his health remainedpoor throughout the treatment. His tragic death underlines the need for early treatment.

I had tinnitus, joint pain and stiffness of joints, along with abdominal discomfort and loss of appetite. I felt full all thetime, even when I hadn’t eaten. Even though I didn’t want to eat, I forced myself to eat. I forced myself because I knew
I needed to have nutritious food. I began to have a noisy song in my right ear that just wouldn’t go away. It was so loud,and I still have it now. If I close my left ear I have trouble hearing. I just kept looking at my tattoo to remind myself ofwhat I had to do and what was required of me. I feel like a much stronger person now.

Either money is made available to build on the progress to date and treatment for MDR-TB is scaled up to thelevels necessary to meet the urgent need in Myanmar, or those who need treatment must carry on waiting. All
the while they are exposing those around them to the risk of infection, while their health deteriorates.
44 WHO, Global Tuberculosis Control 2011, http://www.who.int/tb/publications/global_report/en/
45 WHO. Anti-Tuberculosis Drug Resistance in the World 2008, http://whqlibdoc.who.int/hq/2008/who_htm_tb_2008.394_eng.pdf

The initial hospital stay was two months, and after about five months I slowly began to feel better. My appetite returned,
and I gradually increased my weight to 55 kg. It was tough.
In the future I know I can face anything, no matter how hard, because of the experience I’ve been through with MDR-TB.
It was a long time I had to wait for treatment, but I’m so glad I received it, because I would be dead now without it. I
really appreciate the donors and what they have given. I wouldn’t have been able to afford it if I had been made to pay.
Now I just want to help other people suffering from the disease and show them that it can be overcome. I want otherpeople to receive the treatment I received. Most of all, I want the transmission of the disease to stop.”26

MéDECINS SANS FRONTIèRES

Gap between rhetoric and reality – governments failing to live up to their words

The decision to cancel Round 11 was unprecedented in the Global Fund’s ten-year history. It was takenon the basis that not enough money was available to fund new proposals.
Foreseen donor pledges to the Global Fund have been on a downward track since the disappointing
replenishment conference in 2010 when donors failed to contribute even to the level of the lowest
scenario.46 The Global Fund is currently advocating for an additional $2 billion by 2013 to make up someof this shortfall.47

system. Today, although the Ministry of Health is the main body responsible for healthcare provision,
70 to 80 percent of health expenditure is absorbed by households.49 This is all in a country where 32.7
percent of people live below the poverty line.50
Net Official Development Assistance Received Per Capita 2008-2009 (USD)(World Bank Development Indicator)

International targets for HIV treatment were already woefully off-track. In June 2011, UN member states
admitted their failure to meet the Millennium Development Goal (MDG) of “universal access to treatment
for HIV/AIDS” by 2010. They set a new – oft quoted – target, outside the MDG framework, to increase thenumber of people on HIV treatment to 15 million by 2015, from the 6.6.million on treatment in 2011.
The story that continues to unfold in Myanmar is a tragic example of how far the reality is from therhetoric. These are goals that will never be reached unless the money to meet the need starts to come in.
Instead, just a few months after announcing the HIV treatment target, an entire round of Global Fundmoney was lost. Countries such as Myanmar are finding their efforts to ensure greater access to HIV and
TB treatment condemned to failure.
Millions around the world continue to needlessly suffer and die.
The cancellation of Round 11 means that there will be no new funding opportunities to expand treatment for HIV/AIDS or for TB and its drug-resistant forms until 2014. But diseases don’t respect suchdelayed timelines. HIV and TB will continue to spread – unchecked – in many areas. The time to treat
them is NOW.
The maths is simple. Rapidly scaling up HIV and TB treatment now will save both lives and money. Less
people infected means less lives lost and less people in need of treatment.
With the 3DF changing its focus from HIV and TB in Myanmar to other urgent health needs such as
maternal healthcare, the Global Fund is currently the only substantial donor for funding sustainable HIV
and TB treatment in Myanmar. The Global Fund and donors must walk the talk and raise the resources
necessary for a new funding window in 2012.
Either the Global Fund is replenished or new funding from other sources must be made available
urgently.
The donor community in Myanmar“Honestly, Myanmar is very poor and we can’t afford everything, so we still needto get support, but we haven’t gotten enough support. So I hope we can get more soeveryone who needs ART can receive complete treatment.” – 21-year-old HIV positive man(*The higher level of ODA in Myanmar in 2008 can be attributed to Cyclone Nargis)
Concerns about bureaucratic and other challenges must not dissuade donors from providing assistance
where it is needed, and where it can save lives. Political reform in Myanmar is being reciprocated with aneasing of restrictions from many donors. These developing relationships represent an opportunity to put
access to treatment for HIV and TB sufferers at the top of donor priority lists.
The benefits of ART in resource-poor settings have long been demonstrated. Sustainable funding is the
only answer to ensuring access to lifesaving medicines and activities for those people who need it most.
Conclusion: Myanmar at a critical juncture“I really appreciate the opportunity to do this interview because this is not only aboutme but about other patients who need more support. I hope it can help them to get
more treatment in the future.” – 25-year-old woman living with HIV.
The cancellation of Round 11 means that, with no other substantial funding sources in the pipeline,
the treatment gap in Myanmar will once again widen, with available care and treatment meeting only afraction of the needs, or will even deteriorate further.
Either other funding sources have to be made available, or the Global Fund must be replenished as amatter of urgency.
Most of the elements to close the gap between need and treatment for both HIV and TB exist in
Myanmar. There is acknowledgement, willingness and commitment for scale-up in the country.

CD4 180, currently unable to access treatment.

Ranked 149 out of 187 countries on the UN Human Development Index48, Myanmar is the least
developed country in Southeast Asia. It is also one of the lowest recipients of Official Development
Assistance in the world, receiving a fraction of what some of its Southeast Asian neighbours do.

The HIV/AIDS plans outlined in the Government’s National Strategic Plan (70,000 adults and children
to receive ART by 2015), and its efforts to prioritise treatment in its submission to Global Fund Round
11 (through reaching an additional 46,500 patients in addition to those anticipated to be reachedthrough Round 9), demonstrate this.

Myanmar suffers from an underfunded state healthcare system, while there are encouraging efforts
to increase the health budget, it will be years before the country has a fully comprehensive healthcare

Meanwhile, its ambitious plans to roll out MDR-TB diagnosis and treatment also indicate recognition of
the problem, and a willingness to address it.

46 There is a shortfall of $13 billion needed for the period 2011-2013. The current resource forecast is well below $ 11.7 billion foreseen in 2010, and below the projected demandby countries receiving funding.
47 Global Fund press release 26 January 2012, http://www.theglobalfund.org/en/mediacenter/pressreleases/2012-01-26_The_Global_Fund_Welcomes_USD750_Million_
Promissory_Note_from_the_Bill_Melinda_Gates_Foundation
48 UNDP 2011 Human Development Indicators http://hdrstats.undp.org/en/countries/profiles/MMR.html

49 Ministry of Health, Myanmar, World Health Organization and Health Intervention and Technology Assessment Program (HITAP), A feasibility study of the Community Health Initiativefor Maternal and Child Health in Myanmar, July 2010
50 CIA world factbook https://www.cia.gov/library/publications/the-world-factbook/geos/bm.html

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MéDECINS SANS FRONTIèRES

With a public health sector that will need increased internal resources and time to be able to address themain health needs in the country, those in need of HIV and / or TB/MDR-TB treatment are dependent
on long-term funding by the international donor community.
Of course access to treatment requires more than just funding. Improved access for healthcare providers
to people living with HIV and TB – in communities, clinics and hospitals in urban and rural settings – isalso a vital part of the equation.
Current locations for ART provision are still limited, often forcing people to travel extremely long
distances in search of diagnosis and treatment, which may mean separating families for months at atime. Far greater geographic expansion of ART enrolment, which would have resulted in easier and wider
access for many people living with HIV and TB, was a big part of the plans for Round 11 of the Global
Fund submission.

Recommendations:• International donors must help ensure that the planned scale-up of HIV, TB and MDR-TB treatment
goes ahead. They can do this by:- Increasing funding, both bilateral and multilateral, for HIV and TB programmes in Myanmar- Providing additional funding for the Global Fund in 2012 and actively encouraging other
donors to do the same.
- Supporting the Government of Myanmar in taking the necessary steps to facilitate the planned
scale up of HIV and TB treatment.

The Myanmar Ministry of Health has plans to enable greater access and to support Myanmar’s healthfacilities to increase the number of HIV and MDR-TB patients under care, which is essential to achieving
a substantial, comprehensive and sustainable scale-up of ART and MDR-TB treatment in their own
facilities.
MSF remains committed to fighting HIV, TB and MDR-TB in Myanmar for the foreseeable future but
urges that, for the disease cycle to be broken, substantial scale-up efforts by all relevant actors will benecessary.

• The Global Fund must ensure adequate funding allocations for Myanmar.

For tens of thousands of people in Myanmar, the decisions taken by donors will be – quite literally – thedifference between life and death.

• MSF asks the Government of Myanmar to continue to support the process of decentralising lifesaving
ART and MDR-TB treatment by facilitating increased geographic access, and through simplifying
operational constraints such as importation procedures.

• International NGOs must play their part, and increase support for HIV and TB treatment in Myanmar• MSF is encouraged by the recent efforts by the Government of Myanmar to increase the health budget
and hopes this will continue. The Ministry of Health needs the resources to provide necessary healthcare to the population, inclusive of HIV and TB treatment.

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www.msf.org
email: info@oca.msf.org
telephone: +31 (0)20 5208700