D. HIV/AIDS

The emergence of the HIV epidemic in Myanmar is closely linked to injecting drug use. The epidemic of HIV developed unnoticed and although testing began on a small scale in 1985 there were very few drug users among those tested. It was in 1989 that evidence emerged of high levels of infection among injecting drug users. For example in the Drug Treatment Centre in Myitkyina in Kachin State 95 per cent of patients in 1989 were HIV-positive. In Mandalay a year later 72 per cent of drug patients were positive. However, by 1992 sentinel data demonstrated evidence of the emerging spread of HIV among other high risk groups such as male and female sexually transmitted diseases patients and even among pregnant women in some parts of the country (e.g. Tacheleik and Kawthaung).

Limited ad hoc screening of high-risk population and of blood donors began in Myanmar in 1985 in response to accounts of HIV in neighbouring countries. However, the first case of HIV infection was identified in 1988. Data on detected cases of HIV in Myanmar reveal a steady yearly increase from a total of 323 cases in the year 1989 to 2,001 in 1993 and to 3,689 in 1998. The total detected cases stands at 21,535 as of December 1998 (women represent 14 per cent of the total). Likewise the number of AIDS cases increase year by year and as of December 1998 stand at a total of 2,854. The majority of AIDS cases are in Yangon, the Shan and Tanintharayi states. However, as in many other countries accurate figures about the levels of HIV infection in the country are difficult to determine and estimates of the actual situation in the country far exceed the figures of detected cases. It has been estimated that at the end of 1997 there were 440,000 adults and children living with HIV/AIDS in Myanmar and that some 86,000 people in the country may have already died of AIDS and that about 14,000 children have been orphaned.⁴

⁴ Figures are quoted by the UNDP and UNAIDS.

HIV infections in prisons

There is little information about the prevalence of HIV/AIDS in the prison but it may be considerable since the prison population contains many drug users. The National AIDS Committee has in 1993 trained medical and other prison staff about HIV issues but since that time there has been little dialogue between the Committee and the prison authorities.

Clinical reporting and ad hoc studies

HIV case reporting began in 1992 for suspected hospital patients and AIDS case reporting using the WHO clinical diagnostic guidelines started in 1991 in Yangon. Periodic studies of groups that are not included in routine testing also take place, e.g., studies of seafarers and of truck drivers have been undertaken. To date there has been no voluntary HIV testing within the National Health system. Private tests were available but are considered to be unreliable and do not provide pre- and post-test counselling. Voluntary testing centres will be set up in the near future in Yangon and Mandalay.

Sentinel surveillance

Sentinel surveillance began in 1992 in just nine sites amongst seven high-risk groups. It has continued bi-annually ever since and is now conducted in 21 sites covering all the States and Divisions of the country though not all risk groups are tested in each site. For example drug users are routinely tested in just four to six sites and sex workers, military recruits and blood donors are routinely screened in just two of the 21 sentinel sites, so the data is incomplete. As far as possible it is aimed to achieve a sample of one hundred for each of the risk groups. Furthermore some of the high-risk areas for HIV infection for example, the Jade mining areas, or the border area with India are not included as sentinel testing centres.⁵

⁵ Dr. Hla Htut Lwin of the NAP conducted a study on the border between India and Myanmar in 1994 and found that 90% of drug users on the Myanmar side of the border were infected with HIV.

The HIV sentinel surveillance data provides partial information on infection trends. It clearly demonstrates the steady increase of infection in the general population, which is reflected by the data on pregnant women attending antenatal clinics. Information from the majority of sites has been collected twice yearly since testing began and the percentage of sero-positive women has risen steadily. Thus in March 1992 599 women were tested in five sites and none was positive for HIV. However, by 1998, 3,126 women were tested in 17 sites and overall 1.79 per cent were positive for HIV. There are considerable variations across sites. Thus, in some sites, particularly in the Shan State 4 per cent of women tested in Lashio, 3 per cent in Muse and 2.53 per cent in Tacheleik were found to be positive for HIV. Behavioural data collection as part of the Sentinel Surveillance was added in 1997 in two sites only (Yangon and Mandalay) and consists of four questions on behaviour among risk groups including one on sharing practices among drug users.

HIV among injecting drug users

HIV infection among injecting drug users in Myanmar remains one of the highest in the world and is consistently higher than among any other identified risk group (Tables 5.1 and 5.2). It is not clear however, what proportion of the total infection rates in the country can be reasonably attributable to injecting drug use.

Table 5.1 Sentinel surveillance data for September 1992 to September 1998 for injecting drug users⁶

Year	Number of Sites	Number tested	% HIV-positive
1992	4	366	62
1993	6	549	69
1994	5	471	7
1995	6	475	63
1996	6	461	65
1997	5	445	56
1998	5	399	62

⁶ AIDS Prevention and Control Project, Department of Health, Myanmar

These national figures represent the average for the country and although they conceal regional differences the rates of infections are consistently high. Clinical reports suggest that some drug users are highly mobile so that, for example, drug users who come for treatment in Myitkyna in Kachin State may have contracted HIV while working at the mines in Phar Kant or could have come from anywhere in the country.

In a study conducted by Care Myanmar with AusAID, UNICEF and the National AIDS Programme in 1998, men who were interviewed in Mandalay and Yangon confirmed that disposable needles and syringes are available but are expensive and that they continued to share even though they were aware of the dangers. Many noted that they were fearful of carrying injecting equipment with them in case they were stopped by the police. They had this to say about their injecting habits:

We knew through school health that the disease can be transmitted to another if the needle is shared.... but when we use drugs... as the drug eater is not a doctor, the needle cannot be with us whenever we go. At that time, when we are in a state of great desire, we never care about whose needle it is, we all share.⁷

⁷ 'Like a Moth Chasing the Fire', Umemoto 1998

Injecting drug users in Myanmar become infected early in their injecting career, a pattern that is rarely seen elsewhere. The national surveillance data point to the young age of the HIV infected injecting drug users. A group that is particularly at risk are the rural seasonal migrant workers in the jade and ruby mining areas who move back and forth between the mines and their homes. Many are infected with the HIV after a brief history of drug use. Drug use patterns in these locations pose a particularly high risk for HIV infection. Drugs are injected with a variety of improvised equipment such as eye-droppers with an attached needle or a polyethylene tube with a needle attached. Some of this equipment is impossible to sterilise even if the attempt were made. Moreover most addicts share their injecting paraphernalia and are often injected by professional injectors who also supply the drugs. The mining areas also have a thriving sex industry.

Table 5.2 Sentinel data for different sites 1992-98 (September data): Percentage of HIV-positive injecting drug users

Site	1992	1993	1994	1995	1996	1997	1998
Yangon	66	66	46	47	64	65	61
Mandalay	57	86	83	79	67	80	85
Taungyi	44	27	33	23	29	19	22
Myitkyna	79	95	84	93	86	73	84
Lashio	-	28	-	68	-	28	70
Bamaw	-	-	99	-	-	-	-
Muse	-	-	-	88	86	-	-

Response to HIV/AIDS

The National AIDS Technical Committee was set up in 1989 and was later restructured to become a multi-sectoral National AIDS Committee under the chairmanship of the Minister of Health. However, in practice the HIV/AIDS plan is subsumed under the overall leadership of the National Health Committee, which is the supreme decision-making body in health matters in Myanmar and the current strategy for HIV/AIDS/STD is incorporated and subsumed within the overall National Health Plan for 1996-2001. There is little collaboration between line ministries on HIV/AIDS matters.⁸ A draft UNAIDS strategy to support HIV/AIDS prevention and care in Myanmar for 1999-2001 was prepared by in collaboration with all its sponsoring agencies in the country and in close collaboration with all the relevant line ministries and is awaiting government approval.⁹

⁸ National HIV/AIDS/STD Prevention Programme in Myanmar. National AIDS Programme, Department of Health, 1998

⁹ Draft UNAIDS National Strategy to support HIV/AIDS prevention and care in Myanmar 1999-2001, November, 1998 (not for circulation)

The National AIDS Committee has undertaken large-scale training of health staff and over 40,000 health care workers have been trained (including community volunteers). It has also conducted prevention campaigns within the permitted parameters. In general the State media only permits general information about HIV/AIDS. Thus campaigns about condom use are not permitted and there is little open discussion about sexual matters since pre-marital or extramarital sex are condemned. However, some targeted interventions among high-risk groups (including sex workers and injecting drug users) are ongoing. Myanmar is extremely sensitive to criticisms about its HIV/AIDS policy. However, the National AIDS Committee asserts that the population is in fact well informed about the dangers of HIV/AIDS.

Officially, the government considers HIV to be the third highest health priority in the country following malaria and tuberculosis. The budget allocated specifically to HIV/AIDS prevention is small: approximately US$ 1 million annually plus external assistance of some US$ 1.2-1.5 million, and the National AIDS Committee's staffing is minimal: just 4 1/2 people (two of whom have been 'lent' to the Committee from other divisions of the health ministry). The financial constraints reflect both the chronic lack of funds in the country and perhaps also the ambivalence about HIV/AIDS among policy makers.

The National AIDS Programme identified the following specific objectives:¹⁰

(a) The general community as well as high-risk groups are to be given appropriate information to increase awareness on HIV/AIDS and to promote behavioural change;

(b) Transmission of HIV infection through needles, syringes and surgical equipment are to be prevented;

(c) Training of community leaders, peer educators, health workers and volunteers for health education counselling and provision of care.

¹⁰ National HIV/AIDS, STD Prevention Programme in Myanmar, National AIDS Programme, 1998

The strategies include the reduction of narcotic use and the provision of education programmes including peer training. The activities designed to focus specifically on drug users are at the discretion of those directly involved with drug treatment.

UNAIDS draft National Strategy for 1999-2001 identifies youth as a crucial target for preventive interventions and highlights the issue of AIDS in the context of overall development issues. The recommended strategic approach is to target those groups with the highest known HIV prevalence in the geographical areas with the largest concentrations of such high-risk populations. Thus attention should be given to men with multiple sex partners and their wives, to commercial sex workers and to 'indirect' sex workers, to Injecting drug users and their families and to young people leaving their families to seek work and to cross-border migrants. It is hypothesised that such a targeted approach is likely to have the maximum impact and be most cost effective. The overall objective is to broaden Myanmar's response to HIV/AIDS and to establish a truly multi-sectoral approach. So far the response has been largely a Ministry of Health response. There is little ongoing co-ordination between the National AIDS Programme and the Central Committee on Drug Abuse Control or the Drug Treatment Services.