Today is the day for Medical Unit 3 at Mandalay General Hospital. This is a special consultation for HIV-infected patients who also get tuberculosis. There is a strong association between TB and HIV. Since the immune system is weakened by HIV, many patients develop tuberculosis. It is also important to test TB patients for HIV infection.
In Mandalay district, which has a population of about 1.5 million, most TB cases diagnosed in the public sector are tested for HIV. About 2,000 TB cases are diagnosed each year, and 30% of them will also be diagnosed as HIV-infected. During the five years that TB cases have been tested for HIV, there has been no decrease in the proportion of TB patients found to be HIV-infected. Many people remain unaware of their HIV infection until some signs and symptoms finally reveal it. Very often it is not until patients become sick with TB that they learn they also have HIV infection that may have been acquired 5-10 years earlier. The reservoir of people unaware of their HIV infection looks endless.
Today's patients are all TB/HIV co-infected patients. They are all in advanced stages of HIV infection. Their immune defences, measured by their CD4 count, are low. Most of them have already presented with other diseases associated with a weakened immune system, such as oral candidiasis. This is an infection of the mouth caused by a fungus. It is painful and reduces the patient's ability to swallow. Many patients look seriously ill; they have lost a lot of weight. Some can barely walk and are helped by a family member. And what about these family members? If they are the spouse of the patient, they have a 75% chance of being HIV-infected themselves. Their children will also be infected in 30% of the cases.
Now, doctors have started the consultation, and patients are examined. Later the patients will have their bloodwork analysed; they will attend drug adherence counseling sessions; and, soon after, start the life-saving antiretroviral drugs (ART). These drugs are specifically designed to treat HIV. It is however expected that 20% of today's patients won't be alive in six months. They are indeed already "too far" on their way to die from AIDS.
But our patients are the lucky ones: they have the chance to get started on ART. The Integrated HIV Care programme began in 2005 with the goal of providing antiretroviral therapy to TB/HIV co-infected patients and their family members. The programme was later expanded to all HIV-infected patients, whatever their TB status. Thanks to YADANA/TOTAL, 2,000 patients have been started and supported on antiretroviral drugs. The commitment is for 10 years. Two thousand patients. . . This number looks so big and so small. It is indeed a long time ago that the goal of the IHC programme was to start ART in 200 patients for duration of five years. YADANA/TOTAL agreed to multiply the number of treated cases by 10 and to double the duration of its commitment.
In Myanmar, resources are scarce, and ART is barely available. It is estimated that there are about 250,000 HIV-infected patients nationwide among whom 76,000 patients are in dire need of antiretroviral therapy. If they do not access ART, and most won't, they will die within a year or so. There are about 30,000 people on ART nationwide. On the other side of the curve, 15,000 new infections occur each year in Myanmar.
With the Global Fund to Fight against AIDS, Tuberculosis and Malaria as the single and lonely largest donor, gaps in the "three diseases" funding are enormous, not the mention the needs in many other areas of health.
At the AIDS conference last year, scientists were calling for much more funding for HIV/AIDS. Treatment as prevention is one potential way to curb the HIV epidemic: diagnose people early, before they are too sick, before they have the time to spread the disease, and treat them with ART. Indeed, ART does not only benefit the one taking it. It also benefits the community by decreasing the infectiousness of the treated patient.
We are presently running after HIV, and its newly infected people fuel a never-ending cohort of people in need of ART. Let's jump in front of the mad train of HIV to clench the brake. Let's make early diagnosis a priority: providing more HIV tests and stronger links to HIV care and treatment — and naturally, emphasise prevention too. Multi-pronged prevention campaigns are probably the only one effective at this point.
Today's patients in the outpatient department are lucky. They come from all over Myanmar to access ART. In our programme, we can start about 360 patients on ART each month: which is like a hint of oxygen to breathe, a drop of water in the ocean. So far. . .
Indeed, without additional resources, ART programmes in Myanmar will soon affix "full" signs on the door and the waiting lists will build again. It is a nightmare to envision the day when we will need to tell our patients: "Sorry, come back later, ART will arrive soon . . or later. . ."
Some will be lucky enough to enter the newly funded programme, others will die, but all of them and all of us are waiting for the real moment: when HIV is really tackled and there is a definitive stop to it. Will that be in our lifetime?
Dr Philippe Clevenbergh
Director, The Union in Myanmar