Good wages, plentiful sex workers and cheap heroin mean that HIV is rife in Myanmar's jade-mining state of Kachin, reports Jocelyn Timperley.
“All the conditions are in favour of the spread and transmission of HIV/AIDS,” says Ye Min Htet. “It’s such a complex situation, with the background conflict and the ongoing mining and drug use and prostitution.”
Ye is a Burmese doctor who worked for four years for Médecins Sans Frontières (MSF), the only provider of HIV treatment in the jade-mining area of Kachin State in the northernmost tip of Myanmar.
Workers from across Myanmar migrate there to work in the rich jade and gold mines, where they can earn four or five times as much as labourers in other provinces. And there are readily available temptations to spend those wages on: sex workers are plentiful and heroin is cheap. Kachin State is near the Golden Triangle, one of Asia’s most extensive areas of opium production, and heroin can be bought there for as little as a dollar (around 5–10 per cent of a miner’s daily wage).
These three factors – young workers detached from their family home, cheap heroin and widespread use of sex workers – have all contributed to a rampant HIV rate. One survey showed that nine out of ten drug addicts in the mining districts were HIV positive. Ye says that people are generally aware of the dangers of HIV but often ignore them, using heroin as a refuge to help them survive the extreme working conditions in the jade mines. Heroin 'shooting galleries', where the same needle can be used for many different clients, are increasingly replacing traditional opium dens. Meanwhile, long-running conflict in the area between the military and Kachin ethnic groups, combined with poor communications and transport, hampers testing and treatment efforts.
Almost 20 per cent of the people in Myanmar who inject drugs are now HIV positive, and the number of new diagnoses each year continues to rise. But for many other high-risk groups (including female sex workers, sex workers’ clients and men who have sex with men), the story is different. A 2013 report by UNAIDS showed that the numbers of new diagnoses are falling in these groups, as well as in the general population.
A 2011 government plan is trying to get new infections under control and provide antiretroviral therapy (ART) to more than 100,000 people nationwide by 2016 – an ambitious goal given that in 2013 the number was 68,000. The plan is supported by The Global Fund, an international financing organisation fighting AIDS, TB and malaria. Meanwhile, organisations such as MSF still provide treatment for around 60 per cent of people on ART in Myanmar. There are positive results: the estimated number of deaths caused by AIDS has decreased drastically, from almost 20,000 in 2010 to a projection of fewer than 12,000 in 2015.
The government is also attempting to decentralise HIV expertise. At present, HIV treatment is almost entirely based in a few specialist centres, and the goal is to increase the availability of drugs and diagnostic facilities to under-resourced parts of the country. But this is a slow process.
“They have very good strategic plans for the HIV ART decentralisation, on paper,” said Ye. “But at the implementation process, there are so many delays.”
And money is still an issue. “If they feel unwell and they have a choice between putting food on the table for their family or taking the day off work to go to the clinic, they probably would choose their family,” says Alison Barbour, a medic working for the charity Medical Action Myanmar through the UK-based Green Shoots Foundation to help support local doctors dealing with people affected by HIV/AIDS.
This delay in seeking diagnosis and treatment means that people have often had the virus for longer by the time they see a doctor, making their health poorer and the virus more likely to have spread to others. And although ART drugs are more easily available than they were in the past, a lack of funds can still hinder the doctors in their work. Routine testing of the amount of the virus in the blood of HIV-positive people is prohibitively expensive in Myanmar, so doctors rely on looking at levels of CD4 (a white blood cell used as a marker for the progression of HIV) to look at control of the infection.
The lower the CD4 count, the weaker the immune system. The problem is that everyone’s CD4 levels fluctuate from day to day, meaning that detailed information on the progression of the disease and the success of treatment can be lost.
Since it can take 5–8 years of infection to get to a CD4 count as low as 250, Alison was concerned with the number of patients she saw with low CD4 counts, some in the single figures.
“It implies that, within the community, there must be a lot more HIV that’s just not been diagnosed yet,” she says. “I really worry that we’re only seeing the tip of the iceberg.”